Request Prior Authorization for a Medication

Prior Authorization and Clinical Guidelines

1. Check the formulary to see if prior authorization is required for a medication.
2. If you believe that it is medically necessary for a member to take a medication that is not covered by our pharmacy program: You may submit a coverage review request online through one of these ePA portals: Surescripts, CoverMyMeds, or ExpressPAth.
3. If you do not have access to an ePA system, you can contact 877-417-1839 to submit your request or submit your request by paper with the:
   
   Medication PA form (for Medicaid)
   Medication PA form (for Medicare Advantage)
4. Remember: Always view our Pharmacy Policies prior to submitting your coverage review request.

Medical Benefit Drug Review PA Forms (for select drugs)

• Asthma Monoclonal Antibodies Medical PA form
• Bevacizumab Products Medical PA form
• Compliment Inhibitors Medical PA form
• Erythropoiesis Stimulating Agents Medical PA form
• Filgrastim Products Medical PA form
• GnRH Medical PA form

Inflammatory Conditions Medical PA forms

• Actemra Medical PA form
• Cimzia Medical PA form
• Entyvio/Ilumya Medical PA form
• Orencia Medical PA form
• Simponi Aria Medical PA form
• Stelara Medical PA form
• Infliximab Products Medical PA form
• Pegfilgrastim Products Medical PA form
• Rituximab Products Medical PA form
• Trastuzumab Products Medical PA form