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Pharmacy prior authorization (PA)

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

 

Learn more

Provider manual

Or contact us. We’re here to help.

Electronic PA (ePA)

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  

 

Medicare-Medicaid plan:
 

  • BIN: 610591

  • GRP: RX8827

  • PCN: MEDDADV 

 

You can enroll two different ways:

Other ways to request PA

 

If you don’t want to enroll in ePA, you can request PA:

By phone

Call Provider Relations:
 

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

  • Medicare-Medicaid 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:

                                              

Emflaza (PDF)
                            

Growth hormones (PDF)


Multiple sclerosis agents (PDF)

 

Opioids and morphine milligram equivalents (MME) (PDF)

 

Opioids long-acting and transdermal (PDF) (non-preferred agents)

 

Opioids short and intermediate acting (PDF) (non-preferred agents)           

                      

Oxbryta (PDF)

 

Synagis (PDF)

 

 

Step therapy preferred drug list (Medicare Part B) (PDF)

 

2025 Step therapy preferred drug list (Medicare Part B) (PDF)

 

Abraxane (albumin-bound paclitaxel) Medicare (PDF)

 

Actemra (PDF)

 
Actemra (Tocilizumab) Medicare (PDF)

 

Alpha 1 (PDF)

 

Avastin (PDF)

 
Avsola (infliximab-axxq) injectable Medicare (PDF)

 
Beovu (brolucizumab-dbll) injectable Medicare (PDF)

 

Botulinum toxins Medicare (PDF)

 

Cimzia (certolizumab pegol) Medicare (PDF)

 

Cinqair (PDF)

 

Darzalex (PDF)

 

Darzalex Faspro (PDF)

 
Entyvio (vedolizumab) Medicare (PDF)

 

Erythropoesis stimulating agents (ESAs) medications/dialysis Medicare (PDF)

 

ESA agents Medicare (PDF)

 

Evenity (romosozumab) Medicare (PDF)

 
Eylea (aflibercept) Medicare (PDF)

 

Fasenra (PDF)

 
Pegfilgrastim (fulphila, neulasta, nyvepria, udenyca, and ziextenzo) Medicare (PDF)

 
Filgrastim (granix, neupogen, nivestym, zarxio) Medicare (PDF)

 
Herceptin (trastuzumab) Medicare (PDF)

 
Ilumya (tildrakizumab) Medicare (PDF)

 
Immune globulin (IG) therapy Medicare (PDF)

 
Inflectra (infliximab) Medicare (PDF)

 

Kyprolis (PDF)

 
Lemtrada (alemtuzumab) Medicare (PDF)

 

Leqvio (inclisiran) Medicare (PDF)

 
Lucentis (ranibizumab) Medicare (PDF)

 

Lupron (PDF)

 

Ocrevus (PDF)

 
Orencia (abatacept) Medicare (PDF)

 
Prolia, xgeva (denosumab) Medicare (PDF)

 

Pulmonary arterial hypertension (infusible, inhalation, or injectable medication) Medicare (PDF)

 
Remicade (infliximab) Medicare (PDF)

 
Renflexis (infliximab-abda) Medicare (PDF)

 
Rituxan (rituximab) Medicare (PDF)

 

Signifor (PDF)

 
Simponi ARIA (PDF)

 

Somatuline (PDF)

 
Stelara (ustekinumab) Medicare (PDF)

  

Susvimo (ranibizumab) Medicare (PDF)

 

Trelstar (PDF)

 

Tremfya (guselkumab) Medicare (PDF)

 

Tysabri (natalizumab) Medicare (PDF)

 
Vabysmo (faricimab-SVOA) Medicare (PDF)

 

Visco (PDF)

 

Viscosupplementation medications Medicare (PDF)

 

Zoladex (PDF)

Learn more about PA

 

Non-pharmacy PA

CoverMyMeds is a registered trademark of CoverMyMeds LLC.

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