Pharmacy prior authorization guidelines 

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)

 

Global Exception (PDF)

 

Drug-specific guidelines

 

Actimmune (PDF)

 

Aduhelm (PDF)

 

Ambrisentan-Letairis (PDF)

 

Amphetamine Products (PDF)

 

Anthelmintics (PDF)

 

Aripiprazole Injection (PDF)

 

Armodafinil (PDF)

 

Transthyretin-mediated amyloidosis (ATTR) products (PDF)

 

Atypical Antipsychotic Oral and Transdermal (PDF)

 

Austedo-Austedo XR (PDF)

 

Biologic Response Modifiers In The Treatment of Plaque Psoriasis (PDF)

 

Bosentan-Tracleer (PDF)

 

Botulinum toxins (PDF)

 

Brilinta (PDF)

 

Bronchitol (PDF)

 

Cabenuva (PDF)

 

Cablivi® (PDF)

 

Calcipotriene (PDF)

 

Calcitonin Gene-Related Peptide Antagonist (PDF)

 

Cayston (PDF)

 

Cequa and Cyclosporine Ophthalmic Emulsion (PDF)

 

CGRP Injectable IV Infusion (PDF)

 

CGRP Oral Nasal (PDF)

 

Chelating products (PDF)

 

Cinqair (PDF)

 

Colony stimulating factor (CSF)/myeloid growth factor (MGF) products (PDF)

 

Compounded Drug Products (PDF)

 

Continuous Glucose Monitor (PDF)

 

Corlanor (PDF)

 

COVID-19 OTC Test (PDF)

 

COVID-19 investigational drugs (PDF)

 

COVID-19 molnupiravir (PDF)

 

Cryopyrin-Associated Periodic Syndromes (CAPS) (PDF)

 

Cystic Fibrosis (CFTR) (PDF)

 

Cytokines and cell adhesion molecule (CAM) antagonists (PDF)

 

Dalfampridine (PDF)

 

Daraprim (PDF)

 

Dificid (PDF)

 

Duchenne Muscular Dystrophy Products (PDF)

 

Dupixent Atopic Dermatitis (PDF)

 

Dupixent Other (PDF)

 

Elaprase® (PDF)

 

Emflaza (PDF)

 

Endari (PDF)

 

Entresto (PDF)

 

Epidiolex (PDF)

 

Epoprostenol-Flolan-Veletri (PDF)

 

Eucrisa (PDF)

 

Fabry disease products (PDF)

 

Fasenra (PDF)

 

Fentanyl - Oral and Intranasal (PDF)

 

Gaucher disease products (PDF)

 

Griseofulvin (PDF)

 

Growth hormone products (PDF)

 

HP Acthar (PDF)

 

Hepatitis C products (PDF)

 

Hereditary angioedema (HAE) products (PDF)

 

Hetlioz (PDF)

 

Icosapent Ethyl (PDF)

 

Imcivree (PDF)

 

Immune globulins (PDF)

 

Increlex (PDF)

 

Ingrezza (PDF)

 

Injectable osteoporosis products (PDF)

 

Invega Hafyera (PDF)

 

Invega Sustenna (PDF)

 

Invega Trinza (PDF)

 

Ivermectin (PDF)

 

Jardiance (PDF)

 

Juxtapid (PDF)

 

Korlym (PDF)

 

Lambert-Eaton Myasthenic Syndrome (LEMS) products (PDF)

 

Leqvio (PDF)

 

Lidocaine Topical Patch (PDF)

 

Linezolid (PDF)

 

Linzess (PDF)

 

Lubiprostone (Amitiza) (PDF)

 

Lumizyme (PDF)

 

Methyphenidate Products (PDF)

 

Mepsevii (PDF)

 

Modafinil (PDF)

 

Movantik (PDF)

 

Mulpleta (PDF)

 

Multaq (PDF)

 

Multiple sclerosis products (PDF)

 

Myalept (PDF)

 

Naglazyme (PDF)

 

Nayzilam (PDF)

 

Nucala (PDF)

 

Nuedexta (PDF)

 

Omnipod (PDF)

 

One Touch Diabetic Test Strips (PDF)

 

Onychomycosis (PDF)

 

Opioids (PDF)

 

Opsumit (PDF)

 

Orenitram (PDF)

 

Oxbryta (PDF)

 

Ozempic and Trulicity (PDF)

 

Palforzia (PDF)

 

PCSK9 Inhibitors (PDF)

 

Pregabalin Immediate Release (PDF)

 

Proton Pump Inhibitor Post Limit (PDF)

 

Ranolazine Extended Release (PDF)

 

Recorlev (PDF)

 

Reyvow (PDF)

 

Riociguat-Adempas (PDF)

 

Risperdal Consta (PDF)

 

Rivastigmine Patch (PDF)

 

Roflumilast (PDF)

 

Sensipar (cinacalet) (PDF)

 

Sildenafil-Revatio (PDF)

 

Spinraza (PDF)

 

Spravato (PDF)

 

Strensiq® (PDF)

 

Sucraid (PDF)

 

Sunosi (PDF)

 

Symlin (PDF)

 

Symproic (PDF)

 

Synagis (PDF)

 

Tavalisse (PDF)

 

Urea cycle disorder products (PDF)

 

Tadalafil Products (PDF)

 

Testosterone Agents (PDF)

 

Tetrabenazine (PDF)

 

Tezspire (PDF)

 

Treprostinil-Remodulin (PDF)

 

Tobramycin Inhalation (PDF)

 

Tyrvaya (PDF)

 

Tyvaso (PDF)

 

Uptravi (PDF)

 

Varubi (PDF)

 

Ventavis (PDF)

 

Victoza (PDF)

 

Vimizim (PDF)

 

Voriconazole (PDF)

 

Vyondys 53 with Viltepso (PDF)

 

Vyvgart (PDF)

 

Wakix (PDF)

 

Xifaxan 200mg (PDF)

 

Xifaxan 500mg (PDF)

 

Xiidra (PDF)

 

Xolair (PDF)

 

Zolgensma® (PDF)

 

Zorbtive (PDF)