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
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 Expanded Indications
GLP-1 (glucagon-like peptide-1) Agonists Diabetes
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 Loss Agents- Add-on Coverage for Riders A and B
Weight Management GLP-1/GIP - Add-on Coverage for Riders A and B
Zurzuvae (zoranolone) Prior Authorization with Quantity Limit Criteria