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Our decision-making process
Some medications on our formulary need prior authorization (PA) before they can be dispensed. First, you’ll request PA for a member’s medication. Then, we’ll review your request and make our decision based on nationally recognized prior authorization guidelines. We’ll also use our own custom guidelines.
General guidelines
Non-formulary and PA guidelines (PDF)
Drug-specific guidelines
Transthyretin-mediated amyloidosis (ATTR) products (PDF)
Atypical Antipsychotic Oral and Transdermal (PDF)
Biologic Response Modifiers In The Treatment of Plaque Psoriasis (PDF)
Calcitonin Gene-Related Peptide Antagonist (PDF)
Cequa and Cyclosporine Ophthalmic Emulsion (PDF)
CGRP Injectable IV Infusion (PDF)
Compounded Drug Products (PDF)
Continuous Glucose Monitor (PDF)
COVID-19 investigational drugs (PDF)
Cryopyrin-Associated Periodic Syndromes (CAPS) (PDF)
Cytokines and cell adhesion molecule (CAM) antagonists (PDF)
Duchenne Muscular Dystrophy Products (PDF)
Dupixent Atopic Dermatitis (PDF)
Epogen - Procrit - Retacrit (PDF)
Epoprostenol-Flolan-Veletri (PDF)
Fentanyl - Oral and Intranasal (PDF)
Gaucher disease products (PDF)
Hereditary angioedema (HAE) products (PDF)
Immune Globulins Intravenous (PDF)
Immune Globulins Subcutaneous (PDF)
Lambert-Eaton Myasthenic Syndrome (LEMS) products (PDF)
Lupron Depot Endometrosis - Fibroids (PDF)
Lupron Depot Prostate Cancer (PDF)
Neulasta and pegfilgrastim biosimilars (PDF)
Neupogen and filgrastim biosimilars (PDF)
One Touch Diabetic Test Strips (PDF)
Paroxysmal Nocturnal Hemoglobinuria (PDF)
Pregabalin Immediate Release (PDF)
Proton Pump Inhibitor Post Limit (PDF)
Ranolazine Extended Release (PDF)
Tadalafil (Cialis) for BPH (PDF)
Urea cycle disorder products (PDF)
Vyondys 53 with Viltepso (PDF)
Zoledronic Acid - Reclast - Zometa
For more info
If you have questions or would like a copy of these guidelines, call Provider Services at 1-855-232-3596 (TTY: 711).