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Our decision-making process
Some medications on our formulary need prior authorization (PA) before they can be dispensed. First, you’ll request PA for a member’s medication. Then, we’ll review your request and make our decision based on nationally recognized prior authorization guidelines. We’ll also use our own custom guidelines.
General guidelines
Drug-specific guidelines
Transthyretin-mediated amyloidosis (ATTR) products (PDF)
Atypical Antipsychotic Oral and Transdermal (PDF)
Biologics in Severe Asthma (PDF)
Biologic response modifiers in the treatment of plaque psoriasis (PDF)
Cequa and cyclosporine ophthalmic emulsion (PDF)
Chimeric Antigen Receptor T Cell Products (PDF)
Compounded drug products (PDF)
Continuous glucose monitor (PDF)
COVID-19 investigational drugs (PDF)
Cryopyrin associated periodic syndromes (CAPS) (PDF)
Duchenne muscular dystrophy products (PDF)
Dupixent Atopic Dermatitis (PDF)
Epogen - Procrit - Retacrit (PDF)
Epoprostenol-Flolan-Veletri (PDF)
Fentanyl - oral and intranasal (PDF)
Gaucher disease products (PDF)
Hereditary angioedema (HAE) products (PDF)
Immune globulin intravenous (PDF)
Immune globulin subcutaneous (PDF)
Infliximab Remicade and Biosimilars (PDF)
Insomnia Agents - Dayvigo, Quviviq, Belsomra (PDF)
Lambert-Eaton Myasthenic Syndrome (LEMS) products (PDF)
Liraglutide, Ozempic, Trulicity (PDF)
Lupron Depot Endometrosis - Fibroids (PDF)
Lupron Depot Prostate Cancer (PDF)
Neulasta and pegfilgrastim biosimilars (PDF)
Neupogen and filgrastim biosimilars (PDF)
Nitroglycerin 0.4 percent ointment (Rectiv) (PDF)
Paroxysmal Nocturnal Hemoglobinuria (PDF)
Proton Pump Inhibitor Post Limit (PDF)
Ranolazine Extended Release (PDF)
Sildenafil, Revatio, Liqrev (PDF)
Tadalafil (Cialis) for BPH (PDF)
Urea cycle disorder products (PDF)
Vyvgart - Vyvgart Hytrulo (PDF)
Zoledronic Acid - Reclast - Zometa
For more info
If you have questions or would like a copy of these guidelines, call Provider Services at 1-855-232-3596 (TTY: 711).