Please refer to the member’s specific benefit plan details or contact Customer Service using the phone number on the back of the member ID card to confirm retail pharmacy benefits.
Prior Authorization
To complete a prior authorization, please complete the Prior Authorization Form for Prescription Drugs and submit by fax as indicated on the form.
To understand which medications require approval please see the Standard Prior Authorization Medication List (machine readable) or the Metallic Prior Authorization Medication List (machine readable) depending on the member's plan.
To view clinical criteria please see Prior Authorization and Step Therapy Criteria
Please note: Not all medications require prior authorization. You may contact customer service to determine what medications require prior authorization.
Pharmacy exception requests
Healthcare providers may file a pharmacy exception request when both of the following criteria are met:
- A member is taking an excluded or nonformulary medication
- The provider determines that no other medication listed in the formulary is effective for that member
Exception requests are reviewed based on medical necessity. Factors considered in the review of a pharmacy exception request may include:
- Clinical guidelines
- Formulary alternatives
- Brand/generic availability
- Step therapy
- Quantity limits
Clinical documentation should be provided with each request.
The requesting provider and member will be notified of the determination. If the member’s request is denied, the member has the right to request an appeal.
To complete an exception request, please complete the Exception request form and submit it by fax as indicated on the form.