Some medications may need prior authorization (PA), or approval, before you receive them. Providers need permission to provide certain medications. They’ll know how to do this. And we’ll work together to make sure the medication is what you need.
Learn more about PA
Learn about our criteria for decisions
We use guidelines called criteria to make decisions about medical pharmaceuticals. This helps you get the right medication for your condition. The criteria we use may be from the state of West Virginia or other groups that make criteria for health plans.
Sometimes, the criteria:
Lists preferred medications for your condition
Requires you to try other medications first
Limits how much medication you can get
You and your doctor can get a copy of the criteria. You can also learn more about your medication coverage. Call us at 1-888-348-2922 (TTY: 711).
Learn how to ask for an exception
Sometimes members or providers ask us to consider a different medication than the criteria requires. You or your doctor can ask for an exception. Call us at 1-888-348-2922 (TTY: 711). Then, ask for the Utilization Management department.