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Pharmacy prior authorization (PA)

When a medication isn't on our formulary, or has a utilization management requirement, you’ll want to request pharmacy PA. You can review our current guidelines.

Learn more

Provider manual (PDF)

 

Or give us a call at 1-800-279-1878 (TTY: 711). We’re here for you Monday through Friday, 8 AM to 6 PM.

Pharmacy PA guidelines

Pharmacy PA guidelines

PA guideline chart (PDF)

 

Non-Formulary and Quantity Limits (PDF)

 

Generics First (PDF)

 

Step therapy (PDF)

 

Actimmune (PDF)

 

Adzynma (PDF)

 

Agamree (PDF)

 

Anthelmintics (PDF)

 

Botox (PDF)

 

Cablivi (PDF)

 

Cinqair (PDF)

 

Compounded Drug Products (PDF)

 

Continuous Glucose Monitor (PDF)

 

Daxxify (PDF)

 

Daybue (PDF)

 

Diabetic Test Strips (PDF)

 

Duvyzat (PDF)

 

Dysport (PDF)

 

Epoprostenol-Flolan-Veletri (PDF)

 

Egrifta (PDF)

 

Eligard (PDF)

 

Eohilia (PDF)

 

Esbriet (PDF)

 

Evenity (PDF)

 

Evrysdi (PDF)

 

Fabhalta (PDF)

 

Fensolvi (PDF)

 

Fentanyl - Oral and Intranasal (PDF)

 

Filspari (PDF)

 

Filsuvez (PDF)

 

GamaSTAN (PDF)

 

HP Acthar (PDF)

 

Hyaluronates (PDF)

 

Immune Globulin Intravenous (PDF)

 

Immune Globulin Subcutaneous (PDF)

 

Increlex (PDF)

 

Insomnia Agents - Dayvigo, Quviviq, Belsomra (PDF)

 

Ivabradine (Corlanor) (PDF)

 

Jakafi (PDF)

 

Joenja (PDF)

 

Kalydeco (PDF)

 

Krystexxa (PDF)

 

Leukine (PDF)

 

Leuprolide (PDF)

 

Lodoco (PDF)

 

Lupron Depot Endometriosis - Fibroids (PDF)

 

Lupron Depot PED (PDF)

 

Lupron Depot Prostate Cancer (PDF)

 

Mifepristone (Korlym) (PDF)

 

Miglustat Products (PDF)

 

Mulpleta (PDF)

 

Multaq (PDF)

 

Myobloc (PDF)

 

Nexletol (PDF)

 

Nitroglycerin 0.4 percent ointment (Rectiv) (PDF)

 

Nuedexta (PDF)

 

Octreotide Products (PDF)

 

Ofev (PDF)

 

Ojemda (PDF)

 

Omnipod and V-Go (PDF)

 

One Touch Diabetic Test Strips (PDF)

 

Oncology (PDF)

 

Orilissa (PDF)

 

Orkambi (PDF)

 

Oxervate (PDF)

 

Oxlumo (PDF)

 

Pegasys (PDF)

 

Piasky (PDF)

 

Pombiliti (PDF)

 

Prolia (PDF)

 

Promacta-Alvaiz (PDF)

 

Proton Pump Inhibitors (PDF)

 

Pulmozyme (PDF)

 

Pyrimethamine (PDF)

 

Ranolazine Extended Release (PDF)

 

Recorlev (PDF)

 

Rectiv (PDF)

 

Rivfloza (PDF)

 

Rystiggo (PDF)

 

Sensipar (cinacalcet) (PDF)

 

Signifor (PDF)

 

Signifor LAR (PDF)

 

Skyclarys (PDF)

 

Sohonos (PDF)

 

Soliris (PDF)

 

Somavert (PDF)

 

Spinraza (PDF)

 

Supprelin LA (PDF)

 

Symdeko (PDF)

 

Symlin (PDF)

 

Synagis (PDF)

 

Synarel (PDF)

 

Tavalisse (PDF)

 

Tepezza (PDF)

 

Trikafta (PDF)

 

Trelstar (PDF)

 

Treprostinil-Remodulin (PDF)

 

Triptodur (PDF)

 

Tryvio (PDF)

 

Ultomiris (PDF)

 

Veopoz (PDF)

 

Veozah (PDF)

 

Voydeya (PDF)

 

Vyvgart - Vyvgart Hytrulo (PDF)

 

Wainua (PDF)

 

Winrevair (PDF)

 

Xeomin (PDF)

 

Xphozah (PDF)

 

Xyrem-Lumryz (sodium oxybate) (PDF)

 

Xywav (PDF)

 

Yorvipath (PDF)

 

Zelsuvmi (PDF)

 

Zilbrysq (PDF)

 

Zoledronic Acid - Reclast - Zometa (PDF)

 

Zoryve (PDF)

 

Zurzuvae (PDF)

Electronic PA (ePA)

Electronic PA (ePA)

You need the right tools and technology to help our members. That’s why we’ve partnered with CoverMyMeds® and Surescripts to provide a new way to request a pharmacy PA with our ePA program. 

 

With ePA, you can look forward to saving time with:

 

  • Less paperwork 

  • Fewer phone calls and faxes

  • Quicker determinations 

  • Safe and secure HIPAA-compliant submitted requests

  • Easy upload of clinical documents

Enroll now

Getting started with ePA is free and easy. You’ll need this info to enroll:

 

  • BIN: 610591
  • GRP: RX8837
  • PCN: ADV 

 

You can enroll two different ways:

CoverMyMeds

You can enroll with CoverMyMeds online. Or call 1-866-452-5017.

Surescripts

You can enroll with Surescripts online. Or call 1-866-797-3239.

Other ways to request PA

 

If you don’t want to enroll in ePA, you can request PA:

By phone

Give us a call at 1-800-279-1878 (TTY: 711).

By fax

Check the “PA request forms” section below to find the right form. Then, fax it with any supporting documentation for a medical necessity review to 1-855-799-2553.

Request forms

If you don’t see the right form in the list, you can use the universal pharmacy PA fax form (PDF). Otherwise, check for the drug class or drug name that matches your needs:

 

Member Authorization Release for Appeal Form

ADD-ADHD medications age limit (PDF)

 

Ampyra (PDF)

 

Anti-Allergen (PDF)

 

Antifungal (PDF)

 

Antimigraine Agents (PDF)

 

Atypical antipsychotics, less than 18 years (PDF)

 

Briumvi (PDF)

 

Buprenorphine Oral (PDF)

 

Cinqair (PDF)

 

Colony stimulating factors non-preferred (PDF)

 

Cytokine and CAM Antagonists (PDF)

 

Dupixent (PDF)

 

Fasenra (PDF)

 

Forteo and Tymlos (PDF)

 

GI motility (PDF)

 

GLP1 receptor agonists for cardiovascular risk reduction (PDF)

 

Growth hormone (PDF)

 

Hepatitis C non-preferred (PDF)

 

Hereditary angioedema agents (PDF)

 

Incretin Mimetics Non-Preferred (PDF)

 

Juxtapid (PDF)

Lipotropics Other (PDF)

 

Methadone (PDF)

 

Multiple Sclerosis (PDF)

 

Narcolepsy medications (PDF)

 

Nucala (PDF)

 

Ocrevus (PDF)

 

Opioids (PDF)

 

Palforzia (PDF)

 

Sickle Cell Disease Drugs (PDF)

 

Soma (PDF)

 

Synagis (PDF)

 

Tezspire (PDF)

 

Topical Antifungals for Onychomycosis (PDF)

 

Tysabri (PDF)

 

Vyepti (PDF)

 

Weight Loss Management (PDF)

 

Xolair (PDF)

 

Zolgensma (PDF)

Learn more about PA

 

Non-pharmacy PA

CoverMyMeds is a registered trademark of CoverMyMeds LLC.

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