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).

    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. 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.