PROVIDER (Group) Drugs requiring approval

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 prescriptions

Formulary exception review

A formulary exception review is required if the Rx Plan listed on the member's ID card is B3, M1, M2, or M4 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 we approve the exception, your cost will be charged, based on whether the drug is generic, brand, or specialty.

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.

Emergency prescriptions

You may be eligible for emergency drug refills. Find out here if you qualify.

One-time overrides are available for urgently needed medications that require prior authorization.

When are emergency fills appropriate?

Emergency fills are appropriate in those circumstances where a patient presents at a pharmacy with an 'immediate therapeutic need' for a prescribed medication that requires a pre-authorization due to formulary or other utilization management restrictions.

Immediate therapeutic needs are those where passage of time (i.e., the timeframe required for an Urgent Review) without treatment would result in imminent emergency care, hospital admission OR might seriously jeopardize the life or health of the patient or others in contact with the patient.
Emergency Fill is a short-term, dispensed amount of medication that allows time for the processing of a pre-authorization request. Only the emergency fill dosage of the medication will be approved and paid.

The dosage of the Emergency Fill must either be the minimum packaging size that cannot be broken (e.g. injectable), or the lesser of a 7-day supply or the amount as prescribed. (Depending upon their policies, Health Plans may exceed this baseline dispensing amount.) In the event the medication is to be continued for treatment beyond the emergency fill authorization, health plans may apply formulary or utilization management restrictions that will be reviewed following the health plans' standard procedure.

What is the process for getting approval and payment of an emergency fill?

When a currently eligible member of the health presents at a contracted dispensing pharmacy with an immediate therapeutic need and a corresponding prescription from their provider for a medication requiring a pre-authorization that is specified on the list.

If the health plan has 24/7 availability to respond to phone calls from a dispensing pharmacy but the health plan cannot reach the prescriber for full consultation, an emergency fill will be authorized for dispensing.

-OR-
If the dispensing pharmacy cannot reach the health plan's pre-authorization department by phone as it is outside of that department's business hours, an Emergency Fill can be dispensed by the pharmacy and will be approved and paid.

The health plan's Emergency Fill policy (which must be on their website) will outline their process by which the dispensing pharmacy can secure payment for emergency fill. Two typical processes are:

The dispensing pharmacy will be given a code that can be submitted with the claim that designates the dispensed medication as an emergency fill and will authorize payment.
The dispensing pharmacy will contact the health plan's pre-authorization department within 2 business days to inform them of the Emergency Fill so that a claim for the dispensed medication can be retrospectively submitted and paid.