Pharmacy prior authorization (PA)

When a medication isn't on our formulary, or has a utilization management requirement, you’ll want to request pharmacy PA. You can review our current guidelines.

Learn more

Provider manual (PDF)

Or give us a call at 1-800-279-1878 (TTY: 711). We’re here for you Monday through Friday, 8 AM to 6 PM.

Provider manual (PDF)

Or give us a call at 1-800-279-1878 (TTY: 711). We’re here for you Monday through Friday, 8 AM to 6 PM.

Pharmacy PA guidelines

Pharmacy PA guidelines

Non-formulary and PA guidelines (PDF)

Compounded Drug Products (PDF)

Continuous Glucose Monitor (PDF)

Corlanor (PDF)

Daxxify (PDF)

Daybue (PDF)

Diabetic Test Strips (PDF)

Dysport (PDF)

Epoprostenol-Flolan-Veletri (PDF)

Fentanyl - Oral and Intranasal (PDF)

Icosapent Ethyl (PDF)

Immune Globulin Intravenous (PDF)

Immune Globulin Subcutaneous (PDF)

Increlex (PDF)

Insomnia Agents - Dayvigo, Quviviq, Belsomra (PDF)

Lupron Depot Endometriosis - Fibroids (PDF)

Lupron Depot PED (PDF)

Lupron Depot Prostate Cancer (PDF)

Miglustat Products (PDF)

Mulpleta (PDF)

Multaq (PDF)

Myobloc (PDF)

Neulasta and pegfilgrastim biosimilars (PDF)

Neupogen and filgrastim biosimilars (PDF)

Nucala (PDF)

Nuedexta (PDF)

Octreotide Products (PDF)

Ofev (PDF)

Omnipod (PDF)

One Touch Diabetic Test Strips (PDF)

Penicillamine Trientine (PDF)

Pombiliti (PDF)

Prolia (PDF)

Promacta (PDF)

Proton Pump Inhibitors (PDF)

Pulmozyme (PDF)

Pyrimethamine (PDF)

Ranolazine Extended Release (PDF)

Sensipar (cinacalcet) (PDF)

Treprostinil-Remodulin (PDF)

Triptodur (PDF)

Veopoz (PDF)

Veozah (PDF)

Vyvgart - Vyvgart Hytrulo (PDF)

Zoledronic Acid - Reclast - Zometa (PDF)

Zurzuvae (PDF)

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:

BIN: 610591
GRP: RX8837
PCN: ADV

You can enroll two different ways:

CoverMyMeds

You can enroll with CoverMyMeds online. Or call 1-866-452-5017.

Surescripts

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

Give us a call at 1-800-279-1878 (TTY: 711).

By fax

Check the “PA request forms” section below to find the right form. Then, fax it with any supporting documentation for a medical necessity review to 1-855-799-2553.

Request forms

If you don’t see the right form in the list, you can use the universal pharmacy PA fax form (PDF). Otherwise, check for the drug class or drug name that matches your needs:

Member Authorization Release for Appeal Form