Prior Authorization and Quantity Level Limits

Prior authorization requirements and quantity level limits have been established for select medications in order to promote their appropriate use, while deterring unproven or experimental usages.

• Some medications may have quantity limits
• Some medications may require prior authorization

View the prior authorization list.

Submitting a Prior Authorization Request

Prior Authorization Request Forms (PDF) may be faxed or submitted online.

• Forms must be complete, neat and accurate
• Certain medications require that corresponding chart notes be faxed with the form

Medications Requiring Prior Authorization

• Non-formulary medications must be approved for members on closed formulary plans
  • Formulary alternatives must be tried and failed first

• Medications requiring prior authorization include those that have:
  • Set quantity limits
  • Less expensive options
  • May be prone to overuse
  • Present potential safety issues
  • Limited uses based on scientific studies or FDA approval
  • May be prescribed for conditions which are not covered or that require diagnostic tests to ensure medical benefit

Learn more about:

• Medication policy and criteria
• Medications requiring prior authorization

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