The Pharmacy Prior Authorization program includes four types of reviews:
You can use our Rx Search tool to see if a drug falls into one or more of these categories.
To request a review, the pharmacy or the provider needs to contact our Pharmacy Services Center at 888-261-1756 or fax in a drug-specific online form (see Prior Authorization Drugs section below).
Once the medication is reviewed, we fax a decision to the requesting provider and send the member a confirmation letter about the prescription coverage decision.
Medications for certain conditions-such as migraines, diabetes, or high blood pressure-may need to meet certain requirements before a prescription is covered. See the Prior Authorization Drugs section below to see if the drug requires a prior authorization, quantity limit, or step therapy review.
Type in the name of the drug to view prior authorization criteria, the drug's corresponding medical policy, and a link to an online fax form. In addition to the drug-specific fax form, you can use the Pharmacy Prior Authorization Request fax form to submit all types of pharmacy authorization requests.
Note: The Rx search tool shows drugs that require pharmacy prior authorization common to all plans. For drug review requirements specific to a member's plan, Members can log in to My Rx Choices via MyPharmacyPlus™ to view drug review requirements specific to their plan.