Drugs Requiring Approval

The Pharmacy Pre-approval Program includes four types of reviews:

• Formulary exception (non-formulary)
• Quantity limit
• Step therapy
• Pre-approval

You can use our Rx Search tool to see if a drug falls into one or more of these categories.

To request a review, the pharmacy or the provider needs to contact our Pharmacy Services Center at 888-261-1756 or fax in a drug-specific online form (see Pre-approval Drugs section).

Formulary exception review

A formulary exception review is required if the Rx plan listed on the member's ID card is M1, M2, or M4, and the drug you've selected in the Rx Search tool displays the non-formulary symbol. For these drugs, submit a review using the Pharmacy Formulary Exception Request fax form. If the exception is approved, level cost share is charged based on whether the drug is generic, brand, or specialty. Learn more about drug benefit levels.

Standard versus urgent review requests

• Standard: We review most standard requests within 72 business hours. If we need additional information, the review could take longer.
• Urgent: We typically handle these within 24 hours, whether or not adequate clinical information is available to make a decision. If there's not sufficient clinical information to approve the request, it may be denied.

Once the medication is reviewed, we fax a decision to the requesting provider and send the member a confirmation letter about the prescription coverage decision.

• If the review is approved, the medication is covered by the member's prescription benefits and can be filled at the pharmacy.
• If the review is denied, the medication isn't covered by the member's prescription benefits. The member should then talk to his or her provider about choosing a different drug that's covered.

Quantity limit or step therapy reviews

Medications for certain conditions-such as migraines, diabetes, or high blood pressure-may need to meet certain requirements before a prescription is covered. See the Pre-approval Drugs section to see if the drug requires a pre-approval, quantity limit, or step therapy review.

Pre-approval drugs

Type in the name of the drug to view pre-approval criteria, the drug's corresponding medical policy, and a link to an online fax form. In addition to the drug-specific fax form, you can use the Pharmacy Pre-approval Request fax form to submit all types of pharmacy authorization requests.