Prescription Drugs Requiring Prior Authorization
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This document lists prescription drugs that require prior authorization under the payer's pharmacy benefit; it governs clinicians and pharmacists submitting prior authorization requests processed by Express Scripts, Inc. (ESI).
No material clinical or coverage changes in this revision.
Drugs Requiring Prior Authorization
Prior authorization coverage criteria
Drugs listed in these chunks require prior authorization to be covered by the plan.
Applies to drugs named in chunks 18-37
The drugs listed in the cited segment require prior authorization to be covered under the plan. Coverage is provided only when the prescriber obtains approval from the pharmacy benefit manager before dispensing the medication, per the policy's prior authorization requirement.
There are no explicit exclusions identified within these document segments. The lists enumerate products subject to administrative prior authorization but do not specify exclusion conditions for coverage in the cited chunks.
The provided segment does not include any statements declaring medications or uses as not medically necessary. The content in this excerpt is limited to listing products that require prior authorization.
There are no not medically necessary determinations present in the cited fragment. The text focuses on listing drug names and classifications that are subject to prior authorization under the pharmacy benefit.
Listed Drugs and Coding Notes
| DOJOLVI | Generic Name = triheptanoin |
| DOLOBID | Generic Name = diflunisal |
| DOPTELET | Generic Name = avatrombopag maleate |
| DORYX 80 mg | Generic Name = doxycycline hyclate |
| DORYX DR | Generic Name = doxycycline hyclate |
| DORYX MPC | Generic Name = doxycycline hyclate |
| DOVATO | Generic Name = dolutegravir-lamivudine |
| DOXYCYCLINE HYC 80 mg | Generic Name = doxycycline hyclate |
| doxycycline hyclate dr | Generic Name = doxycycline hyclate |
| DOXYCYCLINE IR-DR | Generic Name = doxycycline |
| YARGESA | Generic Name = miglustat |
| YCANTH | Generic Name = cantharidin |
| YESCARTA | Generic Name = axicabtagene ciloleucel |
| YESINTEK | Generic Name = ustekinumab |
| YEZTUGO | Generic Name = lenacapavir |
| YIMMUGO | Generic Name = immune globulin-intravenous |
| YORVIPATH | Generic Name = palopegteriparatide |
| YUFLYMA | Generic Name = adalimumab-aaty |
| YUPELRI | Generic Name = revefenacin |
| YUSIMRY | Generic Name = adalimumab-aqvh |
What Providers Must Do
Prior Authorization Required
As part of our drug utilization management program, certain prescription drugs require prior authorization before coverage will be approved. Prior authorization requests are processed by our pharmacy benefit manager, Express Scripts, Inc. (ESI). Physicians or authorized providers must call ESI at 1-800-842-2015 to obtain prior authorization prior to dispensing or billing the member's pharmacy benefit. Failure to obtain required prior authorization may result in denial of coverage or benefit under the member's plan.
- Prior authorization requests must identify the drug name, strength, and quantity requested.
- Include supporting clinical documentation as applicable (diagnosis, prior therapies tried, lab results, weight/age for pediatric dosing when relevant).
- For certain opioid extended‑release (ER) products, quantities greater than 90 per month may require prior authorization.
- Generic versions are not always included in the Prior Authorization Program; verify product-level requirements.
- The Schedule of Benefits and group-specific plan documents may further define prior authorization and coverage applicability.
Documentation for Prior Authorization Requests
Providers must submit sufficient documentation to support the medical necessity of the requested drug. At minimum, include the drug name (brand and generic if applicable), dosing regimen, diagnosis or indication, previous therapies and responses, pertinent laboratory or diagnostic results, and any weight/age information necessary for dosing. For specialty or high‑cost agents, attach detailed clinical notes, treatment history, and any genetic or biomarker test results when relevant.
- Drug name (brand and generic)
- Diagnosis / ICD-10 code(s)
- Prior therapies and dates tried with response or rationale for discontinuation
- Relevant labs, imaging, or biomarker results
- Prescribed dose, frequency, route, and duration
- For pediatric patients: age and weight
Documentation Note — Quantity Thresholds
Quantity‑based requirements and exceptions: some medications (for example select opioid ER products) include quantity thresholds (e.g., >90 per month) that trigger additional review and may require prior authorization; submit justification if request exceeds listed thresholds.
- If requesting quantities above published thresholds, include clinical rationale and risk mitigation plan.
- Failure to provide supporting documentation for high‑quantity requests may result in denial.
How to Request Authorization
This document lists drugs that require prior authorization. Providers must submit prior authorization requests for any medication appearing on the list before dispensing when billed under the pharmacy benefit. The inclusion of a medication on this list does not guarantee coverage — verify member benefits and the Schedule of Benefits for plan‑specific limitations.
- Prior authorization applies regardless of site of care when the drug is billed to the pharmacy benefit.
- Some drugs on the list are specialty or high‑cost agents and may have additional submission requirements.
Policy Background
This drug list is maintained as part of the payer's drug utilization management program and may be updated periodically when new products require prior authorization. Inclusion on the list reflects an administrative prior authorization requirement rather than a clinical coverage determination; providers should contact the pharmacy benefit manager to confirm current requirements.
Key Definitions
Quantity Limit Notes
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