Drugs Requiring Approval

  • The Pharmacy Pre-approval Program includes four types of reviews:

    • Formulary exception (non-formulary)
    • Quantity limit
    • Step therapy
    • Pre-approval

    You can use our Rx Search tool to see if a drug falls into one or more of these categories.

    To request a review, the pharmacy or the provider needs to contact our Pharmacy Services Center at 888-261-1756 or fax in a drug-specific online form (see Pre-approval Drugs section).

    Formulary exception review

    A formulary exception review is required if the Rx plan listed on the member's ID card is: M1, M2, M4 or B2 and the drug you've selected in the Rx Search tool displays the non-formulary symbol. For these drugs, submit a review using the Pharmacy Formulary Exception Request fax form. If the exception is approved, level cost share is charged based on whether the drug is generic, brand, or specialty. Learn more about leveled drug benefits.

    Standard versus urgent review requests

    • Standard: We review most standard requests within 72 business hours. If we need additional information, the review could take longer.
    • Urgent: We typically handle these within 24 hours, whether or not adequate clinical information is available to make a decision. If there's not sufficient clinical information to approve the request, it may be denied.

    Once the medication is reviewed, we fax a decision to the requesting provider and send the member a confirmation letter about the prescription coverage decision.

    • If the review is approved, the medication is covered by the member's prescription benefits and can be filled at the pharmacy.
    • If the review is denied, the medication isn't covered by the member's prescription benefits. The member should then talk to his or her provider about choosing a different drug that's covered.
  • Pharmacy management information for providers

  • Pharmacy reviewers at Premera apply company medical policy to assist in the determination of medical necessity. Our medical policies are available to contracted physicians and providers upon request. Specific criteria related to a medical decision for a patient can be requested by calling Pharmacy Services at 888-261-1756, option 2. View our medical policies.

    Our formulary, including prior authorization criteria, restrictions and preferences, and plan limits on dispensing quantities or duration of therapy are available via Rx search.

    Providers can contact pharmacy management staff at 888-261-1756, option 1, to discuss specific prior authorization, step therapy, quantity limits, exception request criteria for unusual cases, and other utilization management requirements/procedures for drugs covered under the pharmacy benefit. Review requests for medical necessity can also be faxed to 888-260-9836. Formulary updates are communicated on a quarterly basis in Provider News.

    Premera updates the formulary and pharmacy prior authorization criteria routinely throughout the year. The Pharmacy and Therapeutics Committee approves all formularies in May. To see the most current information, visit our pharmacy pages.

    Premera has added new review criteria based on clinical best practices and approval by an independent pharmacy and therapeutics committee. The program is designed to promote appropriate drug selection, length of therapy, and utilization of specific drugs while improving the overall quality of care.

    Drugs may be added or deleted from this list without prior notification. If you have questions concerning the Pharmacy Prior Authorization Edit Program, please call the Pharmacy Services Center at 888-261-1756 or fax 888-260-9836, Monday through Friday, 8 a.m. to 5 p.m.

  • Quantity limit or step therapy reviews

    Medications for certain conditions-such as migraines, diabetes, or high blood pressure-may need to meet certain requirements before a prescription is covered. See the Pre-approval Drugs section to see if the drug requires a Pre-approval, quantity limit, or step therapy review.

    Pre-approval Drugs

    Type in the name of the drug to view pre-approval criteria, the drug's corresponding medical policy, and a link to an online fax form. In addition to the drug-specific fax form, you can use the Pharmacy Pre-approval Request fax form to submit all types of pre-approval requests.

    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.