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Prior authorization process for prescriptions

Depending on the prescription, members may need prior authorization to fill the prescription. Having prior authorization means that before a prescription is filled, it’s reviewed to ensure it’s clinically appropriate before the insurance company pays its share of cost. Often these prescriptions may also need to be filled at a network specialty pharmacy.

Prior authorization is important for many prescriptions because you may need:

  • Extra education on safe and effective use of specific medications and devices.
  • Close monitoring of clinical response to the medication(s).
  • Patient-specific dosing, special medical devices, and special handling/delivery.

Examples of medications that may require prior authorization

  • Medications not covered by specific plan
  • Birth control exceptions
  • Dosages in excess of the plan’s quantity limits
  • Step therapy
  • Fertility medications
  • Hepatitis-C

For questions about the prior authorization process and in-network pharmacies, start with the pharmacy customer service number on the back of your ID card.

Please check the Resources section for the Prior Authorization Form for providers.

More information