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).
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. For these drugs, submit a review using the Pharmacy Formulary Exception Request fax form. If the exception is approved, level cost share is charged based on whether the drug is generic, brand, or specialty. Learn more about drug level benefits.
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.