Coverage Determination

The coverage determination process ensures that medication regimens that are high risk, have a high potential for misuse or have narrow therapeutic indices are used appropriately and according to FDA-approved indications.

Please complete and submit a Coverage Determination Request if necessary.

• Electronic Prior Authorization (ePA): Cover My Meds
• Online Form: Request Prescription Drug Coverage
• Pharmacy Prior Authorization Forms

Providers may request an exception for the following:

• Drugs not listed on the Preferred Drug List
• Duplication of therapy
• Prescriptions that exceed the FDA daily or monthly quantity limit
• Most self-injectable and infusion medications (including chemotherapy)
• Drugs that have an age limit
• Drugs included on the PDL that require prior authorization (PA)
• Brand name drugs when a generic exists
• Drugs that have a step therapy (ST) and the first-line therapy is inappropriate