Drugs Requiring Approval

  • On drugs required for certain medical conditions, prior approval may be needed before the prescription is covered. Learn more about situations where prior approval is required.

    Drug Reviews

    Search your drug in our Rx Search tool. Some drugs may require more information before they can be prescribed and covered by the plan.

    Medical Necessity Review

    A Medical Necessity Review is required if you are viewing the Preferred B2, X1, X3, or X4 drug list and the drug you have selected has the Non-Preferred or Non-Formulary symbol, but no Prior Authorization symbol. Please use the Non-Formulary Prior Authorization form to submit a review. If the exception is approved, tier cost share will be charged based on whether the drug is generic, brand, or specialty.

    Drugs that show both a Non-Preferred symbol and a Prior Authorization symbol need to have a Pharmacy Prior Authorization review.

    Prior Authorization NP Button - Non-Preferred

    Prior Authorization PA Button - Prior Authorization

  • Some drugs are part of the Premera Pharmacy Prior Authorization Program. Medications for certain conditions – such as migraines, diabetes, high blood pressure or asthma – may need to meet certain requirements before a prescription is covered.

    Go to the Pharmacy Prior Authorization Drugs tab to see if the drug requires this type of pre-service review.

    How the Program Works

    When a prescription is filled at the pharmacy, the prescription is checked to see if it meets recommended guidelines:

    • If the drug meets these guidelines, the prescription is filled without interruption.
    • If the drug does not meet the guidelines, the prescription will not be filled until it has been reviewed.

    Review Process

    The member or the pharmacy can call the member's provider with notification that a pharmacy Prior Authorization is needed for the drug. The member's provider will need to contact our Pharmacy Services Center to request review.

    Once we receive the provider's information, our review process takes one to two business days. We’ll then send the member a letter confirming the decision made about the member's prescription coverage. We’ll also fax the decision to the member's provider.

    • If the prescription is approved, it will be covered by the member’s prescription benefits, and can be filled at the pharmacy.
    • If the prescription is not approved, it will not be covered by the member’s prescription benefits; the member should talk to his/her provider about an alternate medicine

    Type in the name of the drug for details about prior authorization criteria, and medical policies.

    Note: This list shows drugs that require pharmacy prior authorization that are common to all plans.

    For drug review requirements specific to your plan, log in and use My Rx Choices to find out if your drug requires pharmacy prior authorization.

     

     

    Universal Pharmacy Prior Authorization Form 

    *This form can be used to submit all types of requests for medical necessity.