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 must contact our Pharmacy services center at 888-261-1756 or fax in a drug-specific online form (see Pre-approval Drugs section).

    Sometimes a pharmacy can do a one-time override for urgently needed medication.

    Learn more about emergency overrides.

    Formulary exception review

    A formulary exception review is required if the Rx plan listed on the member's ID card is X1, X3, or X4, 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 we approve the exception, your cost will be charged, based on whether the drug is generic, brand, or specialty. Learn more about drug benefit levels.

    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 we approve the request, the medication is covered by the customer's prescription benefits and can be filled at the pharmacy.
    • If we deny the request, the medication isn't covered by the customer's prescription benefits. The customer should then talk to his/her provider about choosing an alternate drug via Rx Search.

    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. As another option, you can use the Pharmacy Pre-approval Request fax form to submit all types of pharmacy authorization requests.

    Note: The Rx search tool shows drugs that require pharmacy pre-approval common to all plans. For drug review requirements specific to a customer's plan, log in to My Rx Choices via MyPharmacyPlus™ to view drug review requirements specific to their plan.