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.
General guidelines
Drug-specific guidelines
Antidepressant Step Therapy with Quantity Limit
Antifungals with Quantity Limit
ATTR (Transthyretin amyloid) Amyloidosis
Atypical Antipsychotics Step Therapy
Cystic Fibrosis Transmembrane Conductance Regulator (CFTR)
Continuous Glucose Monitor (CGM) Step Therapy
Calcitonin Gene-Related Peptide (CGRP)
Dalfampridine with Quantity Limit
Factor VIII and von Willebrand Factor
GLP-1 (glucagon-like peptide-1) Agonists
Gonadotropin with Quantity Limit
Hyperpolarization-Activated Cyclic Nucleotide-Gated (HCN) Channel Blocker (Corlanor)
Hereditary Angioedema with Quantity Limit
Hepatitis C Direct Acting Antivirals
Interleukin-4 (IL-4) Inhibitor
Interleukin-5 (IL-5) Inhibitors
Self-Administered Oncology Agents
Oral Pulmonary Arterial Hypertension
Parathyroid Hormone Analog for Osteoporosis
Weight Management GLP-1/GIP Prior Authorization with Quantity Limit
Zurzuvae (zoranolone) Prior Authorization with Quantity Limit Criteria