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Provider manual
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Pharmacy PA guidelines
Medicaid guidelines and policies
- Global exception (PDF)
- Continuous glucose monitor (PDF)
- Diabetic test strips quantity limit (PDF)
- Disposable Insulin Pumps (PDF)
- Egrifta (PDF)
- Hyaluronates (PDF)
- Jakafi (PDF)
- Juxtapid (PDF)
- Medicaid step therapy criteria (PDF)
- Mifepristone (Korlym) (PDF)
- Multaq (PDF)
- Nuedexta (PDF)
- Ofev (PDF)
- Pirfenidone (PDF)
- Tavalisse (PDF)
HIDE D-SNP guidelines and policies
Electronic PA (ePA)
You need the right tools and technology to help our members. That’s why we’ve partnered with CoverMyMeds® and Surescripts to provide a new way to request a pharmacy PA with our ePA program.
With ePA, you can look forward to saving time with:
- Less paperwork
- Fewer phone calls and faxes
- Quicker determinations
- Safe and secure HIPAA-compliant submitted requests
- Easy upload of clinical documents
Enroll now
Getting started with ePA is free and easy. You’ll need this info to enroll:
Medicaid:
BIN: 610591
GRP: RX8826
PCN: ADV
HIDE D-SNP plan:
BIN: 610502
GRP: RXAETD
PCN: MEDDAET
You can enroll two different ways:
-
You can enroll with CoverMyMeds online. Or call 1-866-452-5017.
-
You can enroll with Surescripts online. Or call 1-866-797-3239.
Other ways to request PA
If you don’t want to enroll in ePA, you can request PA:
By phone
Call Provider Relations:
Medicaid: 1-866-316-3784 (TTY: 711)
HIDE D-SNP plan: 1-855-676-5772 (TTY: 711)
By fax
Check “Request forms” in the next section to find the right form. Then, fax it with any supporting documentation for a medical necessity review to your plan’s fax number:
Medicaid fax: 866-602-1251
HIDE D-SNP plan fax: 844-242-0914
Request forms
If you don’t see the right form in the list, you can use the uniform prescription drug PA form for your plan:
Otherwise, check for the drug class or drug name that matches your needs: