Drugs Requiring Approval

The Pharmacy Prior Authorization program includes four types of reviews:

• Formulary Exception (non-formulary)
• Quantity Limit
• Step Therapy
• Prior Authorization

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).

Formulary exception review

A formulary exception review is required if the Rx plan listed on the member's ID card is: X1, X3, or X4, and the drug you've selected in the Rx Search tool displays the non-formulary symbol. If the exception is approved, the cost share level is charged based on whether the drug is generic, brand, or specialty. Learn more about drug benefit levels.

There are two types of review requests: standard and urgent.

• Standard: Most standard requests are reviewed within 72 business hours. If additional information is needed, the review could take longer.
• Urgent: These requests are typically handled within 24 hours, whether or not adequate clinical information is available to make a decision. If there's not sufficient clinical information to approve the request, it may be denied.

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.

• If the review is approved, the medication is covered by the member's prescription benefits and can be filled at the pharmacy.
• If the review is denied, the medication isn't covered by the member's prescription benefits. The member should then talk to his/her provider about choosing an alternate drug via Rx Search.

Quantity limit, step therapy reviews

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.

Prior authorization drugs

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. These requests can be faxed to 888-260-9836.