Medicare AdvantagePrior AuthHigh impact
Update to Medical Benefit Drug Coverage for Medical Mutual Medicare Advantage Plans - November 2020
Medical Mutual of Ohio·Rheumatology, Oncology, Hematology +2 more·Pharmacy
Effective date
Jan 1, 2021
We identified it
Jun 20, 2026
Summary
Effective January 1, 2021, Medical Mutual Medicare Advantage plans will require step therapy for multiple specialty medications, with several drugs moving from preferred to non-preferred status. Members new to therapy must trial preferred alternatives before non-preferred drugs can be prescribed, requiring providers to follow coverage determination processes for exceptions.
Action Required
By January 1, 2021: Providers must implement step therapy protocols for Medical Mutual Medicare Advantage members starting new therapies with the listed medications. Update EMR templates to document trial of preferred drugs before prescribing non-preferred alternatives. Billing team must verify step therapy compliance before submitting claims and follow Medical Mutual coverage determination process when requesting exceptions for non-preferred drugs. Claims for non-preferred drugs without proper step therapy documentation or prior authorization will be denied.