Coverage Determination
The coverage determination process for prior authorization ensures that medication regimens that are high risk, have a high potential for misuse, or narrow therapeutic indices are used appropriately and according to FDA-approved indications.
- Electronic Prior Authorization (ePA): Cover My Meds
- Online: Request Prescription Drug Coverage
- Fax or Mail: Coverage Determination Form (PDF)
The coverage determination process is required for:
- Duplication of therapy
- Prescriptions that exceed the FDA daily or monthly quantity limit
- Most self-injectable and infusion medications (including chemotherapy)
- Drugs not listed on the PDL
- Drugs that have an age edit
- Drugs listed on the PDL but still require Prior Authorization (PA)
- Brand name drugs when a generic exists
- Drugs that have a step therapy edit and the first-line therapy is inappropriate
Formulary Medication For Treatment Naïve Patients*
(no previous treatment within a 2 year period):
a. Patient is treatment naïve and has a confirmed diagnosis of hepatitis C; AND
b. Formulary Medication is age-appropriate according to FDA-approved package labeling, nationally recognized compendia, or peer-reviewed medical literature.
*Please note coverage will be provided via a Smart Prior Authorization system where applicable