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
Groups utilizing Drug List A at the time of request may have prior authorization criteria that differ from Drug List B. For Drug List A drug-specific guidelines, check here.
Continuous Glucose Monitor (CGM)
Cystic Fibrosis Transmembrane Conductance Regulator (CFTR)
GLP-1 (glucagon-like peptide-1) Agonists Expanded Indications
GLP-1 (glucagon-like peptide-1) Agonists Diabetes
Gonadotropin with Quantity Limit
Hepatitis C Direct Acting Antivirals
Interleukin-5 (IL-5) Inhibitors
Phosphodiesterase-4 (PDE-4) Inhibitors (topical)
Pulmonary Arterial Hypertension (PAH)
Self-Administered Oncology Agents
Weight Loss Oral Agents - Add-On Coverage for Weight Loss Programs
Weight Management GLP-1/GIP - Add-on Coverage for Weight Loss Programs
Zurzuvae (zoranolone) Prior Authorization with Quantity Limit Criteria