Pharmacy Prior Authorization Requirements

Prior Authorization is a tool that helps decide whether or not a prescription is covered before it is filled. The approval or denial is based on the plan design and focuses on safety and proper medicine use. If a drug on the MediGold formulary requires prior authorization, you will see the abbreviation "PA" in the formulary.

You may also see drugs in the MediGold formulary marked with "B/D". This means that the drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

Please have your pharmacist or doctor call CVS Caremark’s Prior Authorization department at 1-800-294-5979 (TTY 711) before prescribing or administering drugs that require prior authorization.

2020 Prior Authorization Criteria

Part D Coverage Determination and Redetermination Process

Request a coverage determination (also known as a formulary exception) to MediGold’s formulary (by clicking the link below, you will be leaving the MediGold website). You may also call 1-866-785-5714 (TTY 711), 24 hours a day, 7 days a week to complete it over the phone.

Request for Medicare Prescription Drug Coverage Determination

File an appeal related to your Part D prescription drug benefits (by clicking the link below, you will be leaving the MediGold website).

Request for Redetermination of Medicare Prescription Drug Denial

Updated 08/2020