CurrentMedical Mutual - OhioPolicy N/A

MedMutual Advantage Part D Formulary (Drug List) — Coverage Criteria

This document is the MedMutual Advantage Medicare Part D formulary describing covered prescription drugs, coverage rules, restrictions (prior authorization, step therapy, quantity limits), member rights to exceptions, and how members/providers can obtain more information. It affects MedMutual Advantage plan members and their prescribers/pharmacies.

Policy Summary

PayerMedical Mutual - Ohio

PolicyMedMutual Advantage Part D Formulary (Drug List) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes indicated

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization from Medical Mutual before dispensing drugs that are marked PA to avoid coverage denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

monthlyformulary updates posted online

05/19/2026drug list last updated

30 daystemporary transition supply

24 hrsexpedited exception timeframe

6formularly tiers

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria & Formulary Controls

Formulary coverage and restrictions

Covered when ALL of the following are met:

General coverage conditions: Drug is listed on the MedMutual Advantage formulary; prescription is filled at a MedMutual Advantage network pharmacy; drug is medically necessary and other plan rules are followed

See Evidence of Coverage for details.

Restrictions that may apply: Prior authorization, quantity limits, and/or step therapy may apply to certain drugs

Specific requirements are listed in the formulary chart and online prior authorization/step therapy documents.

Transition and temporary coverage: For drugs not on formulary or with restrictions, a temporary 30-day supply will be covered during the first 90 days of membership; 31-day emergency or transition supplies are available in certain situations (long-term care, hospital discharge, etc.)30 days / 31 days

Plan will notify member after dispensing a temporary transition supply.

Coverage conditioned on listed utilization controls

Coverage and access are governed by drug-specific utilization controls as listed; coverage requires meeting those controls where indicated.

Utilization control requirements: When a drug row indicates PA, MO, LTD30, LA, B/D PA, or QL, coverage requires satisfying that specific control (e.g., obtain prior authorization for PA; adhere to quantity limits for QL).

This excerpt contains flags but not the decision criteria for approvals.

Formulary utilization controls

Coverage and utilization rules are enforced at the product level as shown in the formulary.

Product-level requirements: Each product entry is assigned a formulary tier and may include any combination of: PA (prior authorization), MO (medical/mail-order designation), LTD30 (limit to a 30-day supply), ST (step therapy), LA (limited access), B/D PA (part B/part D designation), and QL (specified quantity limits per period).See individual product entries for exact QL/LTD30 values

Provider must request prior authorization when PA is indicated; quantity and LTD30 limits enforced at claim adjudication.

If a drug is not listed on the MedMutual Advantage formulary, it will not be covered by the plan unless one of two conditions is met: the member obtains an approved formulary exception from Medical Mutual, or the prescriber substitutes an alternative drug that is covered. Members and providers should contact Medicare Part D Customer Service (contact details on the plan materials) to confirm whether a drug is covered and to request an exception when appropriate.

Within the excerpt provided there are no lines that identify specific clinical exclusions; the displayed rows show drug entries with tiering and utilization flags (e.g., MO, PA, QL) but do not list conditions or drug classes that are explicitly excluded from coverage.

This partial segment of the formulary does not contain an explicit list of drugs that are categorically excluded from coverage. Exclusions, if any, would be identified elsewhere in the complete formulary or plan documents; the excerpt instead shows drug-level requirements and limits (PA, MO, LTD30, QL) for covered entries.

No entries in this excerpt are labeled with a formal determination of 'not medically necessary.' The table rows shown list utilization controls (for example, MO, PA, QL) but do not include specific 'not medically necessary' rulings in the provided text.

Coding & Quantity Limit Examples

Drug list (no procedure codes in excerpt)mixed

N/A	No CPT/HCPCS/ICD codes listed in this excerpt; entries are drug names, strengths, tiers, and utilization flags.

inv-09: Example quantity limits — selected IV examples

VANCOMYCIN IV piggybackQL (4000 per 10 days)

tobramycin sulfate injection solutionQL (80 per 10 days)

vancomycin IV recon soln 1,000 mg (example)QL (20 per 10 days)

inv-10: Quantity limits examples — Paxlovid dose-pack variations

PAXLOVID dose-pack (150/100 mg) 10-/100-packQL (20 per 30 days)

PAXLOVID dose-pack (150/100 mg) 6/5-packQL (11 per 30 days)

PAXLOVID dose-pack (300 mg: 150x2 +100)

Provider Actions, Prior Authorization & Documentation

Prior Authorization

Prior Authorization Required

Medical Mutual requires prior authorization (PA) for many drugs listed in the formulary. When an entry’s Requirements/Limits field includes “PA” (or “B/D PA”), the prescriber or provider must obtain approval from Medical Mutual before the prescription is filled or the drug is dispensed. Failure to obtain required PA may result in the drug not being covered.

PA is required where the formulary row lists PA or B/D PA — obtain approval prior to dispensing.
Some products (notably many parenteral antibiotics, specialty agents, and most antineoplastics) are broadly subject to PA; check each drug row for PA or related flags (MO, LA, LTD30, QL).
REPATHA SURECLICK is listed with Requirements/Limits = PA; QL (6 per 28 days) — PA must justify the requested quantity.
When a Quantity Limit (QL) is shown (e.g., QL (60 per 30 days)), the PA request must document clinical rationale for quantities exceeding the stated limit.
Many entries list MO (mail-order), LA (limited availability), LTD30 (30-day limit) and ST (step therapy) in addition to PA — meet all listed controls.
If PA is listed together with MO or other modifiers (e.g., PA; MO; LTD30; QL), provide documentation that addresses each requirement to avoid denial.

Background & Formulary Purpose

The formulary is Medical Mutual’s curated list of covered prescription drugs, developed in consultation with clinicians. It identifies therapies the plan considers necessary for quality treatment and indicates applicable utilization controls (e.g., PA — prior authorization; QL — quantity limits; LTD30 — 30‑day supply limits). The formulary may also note when biological products have biosimilars and when substitutions are allowed per state law.

Definitions & Abbreviations

inv-80: formulary / drug list — definitions and related terms

Formulary / Drug listA list of covered drugs selected by Medical Mutual representing prescription therapies believed necessary for quality treatment; 'drug' may refer to a drug or biological product.

Biosimilar / interchangeable biosimilarA biosimilar is an alternative to an original biological product; some biosimilars are designated interchangeable and may be substituted depending on state law.

Drug TierCategorization of drugs into tiers (Tier 1 Preferred Generic through Tier 6 Select Care) used to determine cost-sharing and special handling; Tier 5 specialty is limited to a 30-day supply (LTD30).

AbbreviationsPA = Prior Authorization; QL = Quantity Limit; ST = Step Therapy; MO = Mail-Order / Mail-Order availability; LTD30 = limited to 30-day supply; LA = Limited Availability; B/D PA = may be covered under Part B or D.

inv-81: biosimilar / interchangeable biosimilar

Step Therapy Rules & Notes

Step therapy summary	Source / notes
Member must try specified first-line drugs before plan will cover alternative drugs for the same condition	Policy states step therapy may require trying designated first-line drugs prior to coverage; see formulary and step therapy documents for drug-specific sequences.

Step therapy requirement	Documented example / implication
Must try specified first-line agent(s) before coverage of alternatives	Abbreviation ST defined as Step Therapy; the formulary indicates ST may be applied — specific agent sequences are in supporting step therapy documents.

High-cost inhaled/specialty antibiotics	Utilization controls noted
Certain high-cost inhaled or specialty antibiotics (e.g., ARIKAYCE, CAYSTON) require prior authorization and limited access before coverage	Table entries show ARIKAYCE = PA; LA; LTD30 and similar LA/PA/LTD30 flags for specialty inhaled antibiotics; supporting utilization-control docs referenced.

Explicit step sequences present?	Implication
No explicit step-therapy sequences detailed in excerpt	Therapeutic class groupings and tiering are shown which may indicate preferred agents; explicit step-failure or sequencing rules are referenced in separate step therapy documents.

LA / MO flags meaning	Operational note
Some products list 'LA' (Limited Availability) or 'MO' (Mail-Order/Medical Only) suggesting additional utilization controls or access routes	Abbreviations defined at table start: LA = Limited Availability; MO = Mail-Order Drug/medical-only indicators — check full table header for exact operational definitions.

PA / MO prevalence	Implementation
Many agents show 'MO' and some 'PA' indicating payer step/authorization processes	Follow the Requirements/Limits column for each drug — PA requires prior authorization; MO entries indicate mail-order or medical-only handling and may require additional authorization steps.

Formulations subject to ST	Examples from table
Some formulations are subject to step therapy (ST) prior to coverage	Examples: AUVELITY listed with Requirements = ST; certain diazepam entries and EXXUA-related formulations include ST in Requirements/Limits.

Branded formulations marked ST	Examples / notes
Some branded or specific formulations are marked 'ST' indicating step therapy applies	EXXUA oral tablet extended-release entries and certain branded capsules are annotated ST; refer to formulary rows for product-specific ST requirements.

ORENITRAM titration kits	Utilization controls / limits
ORENITRAM month titration kits include PA and MO and have LTD30 and QL values before ongoing coverage	Table lists ORENITRAM Month 1/2/3 titration kits with Requirements = PA; MO; LTD30 and QL (e.g., 168 per 180 days, 336 per 180 days, 252 per 180 days) indicating utilization controls prior to continued coverage.

MO or PA requirement	Policy implication
MO or PA may be required prior to coverage as indicated per drug entry	Multiple formulary entries show Requirements/Limits including MO and PA; when PA is listed the provider must obtain authorization before dispensing to avoid denial.

Formulary tiering and step expectations	Operational note
Formulary tiering indicates preferred lower-tier agents are expected prior to higher-tier coverage	Drug Tiers defined in abbreviations (Tier 1–Tier 6); tiering and examples in the formulary suggest preference for lower-tier agents which may be enforced via step edits or exception processes.

Quantity Limits (Selected Examples)

Site-of-Care & Benefit Design Notes

Note

Policy Summary

PayerMedical Mutual - Ohio

PolicyMedMutual Advantage Part D Formulary (Drug List) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes indicated

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization from Medical Mutual before dispensing drugs that are marked PA to avoid coverage denial.

SourceLink

On This Page

inv-11: Quantity limits appearing in table examples

COMETRIQ ORAL CAPSULE 140 mg112 per 28 days

KISQALI (some rows)63 per 28 days

MEKINIST ORAL RECON SOLN20 per 28 days

inv-12: Quantity limits (examples)

VITRAKVI oral capsule/solution (various strengths)QL (60 per 30 days / 120 per 30 days)

ZALTRAPQL (600 per 30 days)

VIZIMPROQL (30 per 30 days)

inv-13: Example quantity limits — exact table values

NURTEC ODTQL (16 per 30 days) or QL (24 per 180 days)

acetaminophen-codeine oral solution 120/12 mg/5 mlQL (4500 per 30 days) / alternative QL values shown

carbamazepine oral suspension / tabletsQL (180 per 30 days); QL (90 per 30 days); QL (60 per 30 days)

inv-14: Sample quantity limits — topical / patch / otic examples

glatiramer 40 mg/ml syringe12 per 28 days

fentanyl transdermal patch10 per 30 days (other variant shows 60 per 30 days)

OTIC STEROID / ANTIBIOTIC (example row)7.5 per 7 days

inv-15: Quantity Limits examples — high-value oral solution and vancomycin

diazepam oral solution 5 mg/5 ml (1 mg/ml)QL (1200 per 30 days)

vancomycin oral capsule 125 mgQL (40 per 10 days)

VANCOMYCIN IV piggyback (other bag sizes)QL examples: 9 per 30 days; QL (4050 per 10 days) in table variants

inv-16: Quantity limits (examples) — assorted QL formats

exenatide subcutaneous pen (example)QL (2.4 per 30 days) or other pen-pack QL values

metformin (various ER entries)QL (30 per 30 days) or QL (120 per 30 days) depending on entry

REPATHA SURECLICK / REPATHAQL (6 per 28 days)

Denial Risk

Denial Risk if Authorization or Limits Not Met

Prior authorization and other utilization controls are frequently enforced and may lead to claim denial if not satisfied. Entries tagged with PA, MO, ST, LA, LTD30 or explicit QL values typically require prior review or additional documentation; claims submitted without an approved authorization or supporting documentation may be denied.

Prior authorization often required for high-tier, specialty, parenteral, and oncology agents — check Requirements/Limits before prescribing.
Utilization controls (PA, MO, LA, LTD30, QL, ST) trigger review and potential denial if criteria are not met.
PA and quantity limit enforcement: requests exceeding QL values must include justification in the PA submission.
PA/requirements may trigger denial — obtain approval or submit an exception request prior to dispensing to reduce denial risk.

Documentation Required

Documentation Required for PA and Quantity Limits

Providers must submit supporting clinical documentation with PA requests and when requesting quantities beyond QL limits. Documentation should explain the medical necessity for the drug, why step therapy or preferred alternatives are not appropriate (if requesting an exception), and any other specifics noted in the Requirements/Limits field (e.g., MO, LA).

When requesting a formulary or tiering exception, the prescriber must provide a supporting statement explaining the medical reasons for the exception; Medical Mutual generally decides within 72 hours (or 24 hours for expedited requests).
For PA requests that include a QL, include clinical justification for the requested quantity and expected duration of therapy.
Refer to the formulary header legend for the meaning of abbreviations (PA, MO, QL, ST, LA, LTD30) to ensure correct documentation is supplied.
Quantity limit documentation examples are provided for certain products (e.g., enoxaparin syringe QL values); follow these when submitting PA/QL requests.

Step Therapy

Step Therapy, Benefit/Designation & Related Flags

Step therapy (ST) and benefit/designation indicators (B/D PA) appear across the formulary. Where ST or B/D PA is noted, the plan may require trial of specified first-line agents (or determination of Part B vs Part D coverage) before covering alternatives. Specific step sequences are not shown in this excerpt — follow Medical Mutual’s PA and step-therapy procedures and consult plan materials for full rules.

ST means a required trial of preferred drug(s) before coverage of the requested drug; prescribers should document prior trials and reasons for failure.
B/D PA indicates the drug may be covered under Medicare Part B or Part D depending on use/setting; additional information may be required to determine coverage.
Some entries include LA, MO or other flags that affect where/how the drug is dispensed — review the Requirements/Limits field closely.

Note

Where to Get Coverage Details & How to Request Exceptions

Where to get coverage details and how to request exceptions: consult Evidence of Coverage and plan materials or contact Customer Service. The formulary and supporting documents (posted at MedMutual.com/Formulary) explain prior authorization, step therapy, quantity limits, and exception processes. You may request exceptions or expedited reviews per the procedures outlined in plan materials.

Visit MedMutual.com/Formulary for the full formulary, PA and step therapy policies, and the meaning of table symbols.
To request a formulary/tiering/coverage exception or to waive PA, ST or QL, contact Medical Mutual and provide the prescriber’s supporting statement; standard decisions within 72 hours, expedited within 24 hours when applicable.
Customer Service contact information and the formulary update date are shown on the formulary cover pages — use those resources for plan-specific questions.

Biosimilar / interchangeable biosimilar (definition)Some biosimilars are interchangeable and, depending on state laws, may be substituted for the original biological product at the pharmacy without a new prescription.

Biologic alternativeBiosimilars generally work like the original biological product and may cost less.

Reference to Evidence of CoverageSee Evidence of Coverage, Chapter 5, Section 3.1 for further discussion of drug types and biosimilars.

inv-82: Drug Tier — categorization and notable limits

Drug Tier categoriesTier 1 Preferred Generic through Tier 6 Select Care used to determine cost-sharing and special handling.

Tier 5 specialty limitTier 5 includes very high-cost drugs and is limited to a 30-day supply (LTD30).

Tier 6 Select CareIncludes certain low-cost generic maintenance drugs for lowest copays.

inv-83: Abbreviations — standard symbols used in Requirements/Limits

Abbreviations listPA = Prior Authorization; QL = Quantity Limit; ST = Step Therapy; MO = Mail-Order; LTD30 = limit to 30-day supply; LA = Limited Availability; B/D PA = may be covered under Part B or D.

$35/Mth insulin capYou won't pay more than $35 for a one-month supply of each insulin product covered by the plan.

Reference to table headerSee the beginning of the formulary table for full symbol explanations used throughout the list.

inv-84: MO — program/availability code

MO (Mail-Order / program-level code)Requirement/limit code shown throughout the list indicating mail-order availability or a program-level management flag.

MO usage in tableMO is used repeatedly in Requirements/Limits entries and may require following mail-order or program-specific procedures.

Refer to table headerMeaning and operational use of MO is described at the beginning of the formulary table.

inv-85: PA — prior authorization requirement

PA (Prior Authorization)Prior authorization is required for certain drugs; the prescriber must obtain approval before the prescription is filled or the plan may not cover the drug.

PA noted across many agentsMany parenteral antibiotics, specialty agents, and antineoplastic drugs are marked 'PA' in the Requirements/Limits column.

PA consequencesFailure to obtain PA when required may result in denial of coverage for the drug.

inv-86: QL — definition and enforcement note

QL (Quantity Limit) — generalQuantity limit specifying maximum units allowed per defined time period (examples shown in many entries as 'QL (40 per 10 days)', 'QL (60 per 30 days)', etc.).

QL enforcementWhen a QL is shown, documentation may be required to justify quantities above the listed limit during a PA request.

Common QL formatsQL values appear per 7, 28, 30, or 180 day periods depending on the product entry.

inv-87: LTD30 — limited to 30-day supply

LTD30Tier 5 specialty drugs are limited to a 30-day supply (LTD30) as indicated in the table.

Practical effectLTD30 entries enforce a maximum supply duration for specialty/high-cost agents; refer to drug row for exact QL values.

See table headerFull operational definitions of LTD30 and related symbols are provided at the start of the formulary table.

inv-90: PA / MO / LA / LTD30 / QL — utilization control abbreviations

PA; MO; LA; LTD30; QL — table abbreviationsCommonly used utilization controls in the Requirements/Limits column (PA = prior authorization; MO = mail-order/management; LA = limited availability; LTD30 = 30-day limit; QL = quantity limit).

B/D PAB/D PA indicates the item may be covered under Medicare Part B or D depending on use/setting and may require additional documentation.

ReferenceSee table header for complete symbol explanations used throughout the drug list.

inv-91: QL / PA / MO — core definitions

PA definitionPrior authorization — the Plan requires approval before filling certain prescriptions; absence of approval may result in non-coverage.

MO definitionMO indicates mail-order availability or a program-level management code.

QL definitionQuantity Limit — maximum units allowed per specified time period; values shown in individual drug rows.