Health New England Medicare Advantage conducts utilization review of the medical care (Medicare Part C) and prescription drugs (Medicare Part D) you receive under our plan. The goal of utilization management is to ensure that the care that our members receive is medically necessary. These requirements and limits ensure that our members use their medical and prescription benefits in the most effective way and also help us control plan costs.

A team of doctors and/or pharmacists developed these requirements and limits for our plan to help us provide quality coverage to our members. Health New England Medicare Advantage reviews medical necessity in three ways which includes prior authorization, concurrent review and retrospective review.

For a list of medical care, services, supplies and equipment that require "prior authorization" refer to the Benefit Chart in your Evidence of Coverage. For members with prescription drug coverage (Medicare Part D), we have additional requirements for coverage. These requirements can be found on our  Drug Requirements & Limits page.