Drugs requiring approval

Some drugs require approval to be covered.

The pharmacy Prior Authorization program includes four types of reviews:

Formulary exception (non-formulary)
Quantity limit
Step therapy
Pre-approval

Covered drug lists

You can use our Covered drug lists to see if a drug falls into one or more of these categories.

To request a prior authorization review, the pharmacy or the provider must contact our pharmacy services center at 888-261-1756 or submit a pharmacy prior authorization request fax form for a specific drug. Sometimes a pharmacy can also do a one-time override for urgently needed medication.

Learn more about emergency overrides

Note: For drug review requirements specific to a customer's plan, Members can log in to My Rx Choices via MyPharmacyPlus™ to view drug review requirements specific to their plan.

Formulary or pharmacy exception

A formulary exception review is required if the Rx Plan listed on your member ID card is M1, M2, or M4 and you have been prescribed a drug that is not on the list of covered drugs. For these drugs, submit the Pharmacy Exception Request form by fax.

If you are covered by a Washington state fully insured plan, your prescription may be subject to a set of guidelines and rules (formulary exception, step therapy, dosage limitations, or therapeutic substitution) that consider whether that drug is appropriate for treating you and your condition. If your prescription is rejected under these guidelines, your provider may request an exception by submitting the Pharmacy Exception Request form by fax. For these pharmacy exception reviews, we apply this medical policy as of January 1, 2021.

We review most standard formulary and pharmacy exception requests within 72 hours and urgent requests within 24 hours. If we need additional information, the review could take longer.

Standard versus urgent review requests

Standard: We review most standard requests within 72 business hours. If we need additional information, the review could take longer.
Urgent: We typically handle these 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 we approve the request, the medication is covered by the customer's prescription benefits and can be filled at the pharmacy.
If we deny the request, the medication isn't covered by the customer's prescription benefits. The customer should then talk to his or her provider about choosing a different drug that's covered.

Quantity limit or 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 to see if the drug requires a prior authorization, quantity limit, or step therapy review.

Prior authorization drugs

Select the name of the drug to view prior authorization criteria, the drug's corresponding medical policy, and a link to an online fax form. As another option, you can use the Pharmacy Prior Authorization Request fax form to submit all types of pharmacy authorization requests.

Select a drug

Note: The Rx search tool shows drugs that require pharmacy prior authorization common to all plans. For drug review requirement specific to a customer's plan, Members can log in to My Rx Choices via MyPharmacyPlus™ to view drug review requirements specific to their plan.

Requesting a HIV PrEP (human immunodeficiency virus pre-exposure prophylaxis) drug cost share exception

If you have preventive benefits and you think your HIV PrEP drug should be available at no cost under your health plan, your provider may request an exception by submitting the Pharmacy Exception Request form by fax. For these pharmacy exception reviews, we apply this benefit coverage guideline. We review most standard exception requests within 72 hours and urgent requests within 24 hours.