Pharmacy prior authorization guidelines

Sometimes, before receiving a service or prescription, a provider will want to ensure that it’s covered by your insurance. Prior authorization means that your health plan will review the services or prescriptions requested from a provider for medical necessity and appropriateness before you receive them. If you do not see your disease state or medication, a prior authorization can still be submitted for review.

Drug-specific guidelines

Acthar

Alhemo

ATTR Amyloid Cardiomyopathy

Benlysta (belimumab)

Biologic Immunomodulators

Carbaglu (carglumic acid)

Continuous Glucose Monitor (CGM)

Cobenfy

Colony Stimulating Factors

Constipation Agents

Cystic Fibrosis Transmembrane Conductance Regulator (CFTR)

Galafold (migalastat)

GLP-1 (glucagon-like peptide-1) Agonists Expanded Indications

GLP-1 (glucagon-like peptide-1) Agonists Diabetes

GNRH-LUPRON

Gonadotropin with Quantity Limit

Growth Hormone

Hemlibra

Hepatitis C Direct Acting Antivirals

Hereditary Angioedema

Immune Globulins

Insomnia Agents

Insulin Pumps

Interleukin-5 (IL-5) Inhibitors

Interstitial Lung Disease

Ivermectin

Jynarque

Levalbuterol HFA

Lice-Scabies Treatment

Mavenclad

Migraine Agents

Multiple Sclerosis Agents

Obizur

Opioids ER

Parathyroid Hormone Analog for Osteoporosis

Phenylketonuria

Phosphodiesterase-4 (PDE-4) Inhibitors (topical)

Prolia (denosumab)

Pulmonary Arterial Hypertension (PAH)

Quantity Limit Exceptions

Seizure, Nasal Rescue Agents

Self-Administered Oncology Agents

Somatostatin Analogs

Strensiq (asfotase alfa)

Substrate Reduction Therapy

Weight Loss Agents- Add-on Coverage for Riders A and B

Weight Management GLP-1/GIP - Add-on Coverage for Riders A and B

Xolair (omalizumab)

Zinc

Zurzuvae (zoranolone) Prior Authorization with Quantity Limit Criteria

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