Sentara Medicare Formularies (Covered Drugs) & Utilization Management Requirements

A formulary is a list of covered drugs. Some prescription drugs covered under Sentara Medicare plans have utilization requirements to ensure safe and appropriate use. These requirements apply to calendar year 2026 and may include:

  1. Prior Authorization
  2. Step Therapy
  3. Quantity Limit

Utilization requirements vary by plan and by drug.

Utilization requirements vary by plan and by drug.

CY2026 Prior Authorization Criteria – Sentara Community Complete Select (HMO D-SNP) CMS Contract H2563, PBP 020

CY2026 Prior Authorization Criteria – Sentara Community Complete FIDE  (HMO D-SNP) CMS Contract H4499, PBP 001

 
CY2026 Step Therapy Criteria – Sentara Community Complete Select (HMO D-SNP) CMS Contract H2563, PBP 020

CY2026 Step Therapy Criteria – Sentara Community Complete FIDE (HMO D-SNP) CMS Contract H4499, PBP 001

Drug Prior Authorization Forms

To submit a Medicare Part D Drug Coverage Determination or Exception request, please refer to the Pharmacy Part D Initial Coverage Determination, Exception Requests, or Continuous Glucose Monitor and Supplies section on this page. 

Continuous Glucose Monitors and Supplies

To submit a Coverage Determination or Exception request, please refer to the Pharmacy Part D Initial Coverage Determination, Exception Requests, or Continuous Glucose Monitors and Supplies section on this page.

Medicare Part B Medical Drugs

Medicare Part B Medical Drugs may require a Prior Authorization depending on the drug. 

Sentara Medicare Part B Preferred Step Therapy Drug List

Sentara Medicare Part B Drug Policy Criteria 

To submit a request for a Part B Medication that requires Prior Authorization, please Fax the Medication Precertification Request form: 

Form can be submitted to:
Sentara Health Plans
Fax: 1-844-895-3232 

Sentara Medicare Medical Medication Precertification Request

If you do not find your drug on either the links list above under Medicare Part B section, access the Prior Authorization Lookup Tool (PAL) to verify if the drug requires a Prior Authorization.

Pharmacy Part D Initial Coverage Determination, Exception Requests, or Continuous Glucose Monitor and Supplies

If a prescription drug is not covered, has limits, or requires special approval under your Sentara Medicare plan, you have the right to request:

  1. Coverage Determination (initial decision)
  2. Formulary Exception
  3. Appeal (Redetermination)

These rights apply to calendar year 2026 and follow Medicare Part D requirements, as described the Sentara Medicare CY2026 Evidence of Coverage (EOC).

Sentara Community Complete Select (HMO D-SNP) Medicare Prescription Drug Coverage Determination Request Form (CY2026) CMS Contract H2563, PBP 020

Sentara Community Complete FIDE Select (HMO D-SNP) Medicare Prescription Drug Coverage Determination Request Form (CY2026) CMS Contract H4499, PBP 001

Sentara Medicare Plans CY2026 Medical Necessity General PA Form

Coverage Determination forms can be submitted to:

Sentara Health Plans
Appeals and Grievances
PO Box 62876
Virginia Beach, VA 23466

Fax: 1-800-750-9692

Pharmacy Redetermination or Part D drug Appeal

If Sentara Health Plans denies a request for Medicare prescription drug coverage, you may request a redetermination or appeal. Instructions for submitting requests by mail or fax are included on each form. Expedited requests must include a statement explaining why waiting for a standard decision could seriously harm your health.

Sentara Community Complete Select (HMO D-SNP) Medicare Prescription Drug Redetermination (Appeal) Request Form (CY2026) CMS Contract H2563, PBP 020

Sentara Community Complete FIDE Select (HMO D-SNP) Medicare Prescription Redetermination (Appeal) Request Form (CY2026) CMS Contract H4499, PBP 001

Redetermination forms can be submitted to:

Sentara Health Plans
Appeals and Grievances
PO Box 62876
Virginia Beach, VA 23466 

Fax: 1-866-472-3920