Preauthorization Required

Coverage of drugs is based on medical necessity. For certain drugs, preauthorization (PA) is required before the plan will cover the medication. If you do not obtain required preauthorization, the member may be financially responsible for the drug's full retail price.

• Preauthorization required for select products — PA flags are shown in the product lists (e.g., many specialty, oncology, pulmonary arterial hypertension, and higher‑tier agents).
• Absence of a required PA may result in claim denial or member financial responsibility.

Prior Authorization for Listed and Higher‑Tier Drugs

Some listed drugs and higher‑tier products (notably Tier 5–6 and many specialty/oncology agents) carry a Prior Authorization requirement. Examples from the formulary include multiple oncology agents, PAH agents (e.g., Ambrisentan, Alyq), and certain Tier 5–6 injectables and oral specialty products.

• Look for (PA) next to drug entries in the product lists — these products require prior authorization before coverage is approved.
• Many Tier 5–6 products and specialty injectables have PA + QL + M flags; review the specific drug row for all requirement flags.

Step Therapy Requirement and Risk

Step therapy (ST) requires trying an alternative therapy first; coverage may be denied if step requirements are not met. Step therapy most often applies to brand‑name and certain specialty products.

• Products tagged (ST) in the formulary must meet step‑through criteria prior to coverage.
• Failure to satisfy step therapy requirements can cause claim denial or additional processing delays.

Requirement Flags and Denial Risk

Quantity limits (QL), age limits (AGE), medical justification (M), step therapy (ST), and prior authorization (PA) flags indicate additional requirements. If the corresponding requirement is not met or documented, claims may be denied or require additional review.

• (QL): Quantity limits — exceeding limits may require PA or documentation and can result in denial.
• (AGE): Age limits — verify member age for product eligibility.
• (M): Medical documentation may be required to support medical necessity.
• (ST)/(PA): Step therapy or prior authorization flags present on product rows are potential denial triggers if not satisfied.

Documentation Expectations for Flagged Products

Documentation must support any flagged requirement (PA, QL, ST, M, AGE). Provide clinical rationale, prior treatment history, relevant labs or imaging, and member age when applicable to expedite reviews.

• For PA requests include diagnosis, prior therapies and dates, reason for failure or intolerance, and expected duration of therapy.
• For QL or ST exceptions, include dosing history and justification for exceedance or bypassing step therapy.
• Use the Drug Coverage Exception Form (available on our website) to request coverage for noncovered drugs or to request exceptions.
• Incomplete documentation may delay review or lead to denial.

Coverage Exception Requests

Coverage exception requests (Drug Coverage Exception) may be submitted when a drug is not covered or when a member needs an exception to PA/QL/ST requirements. These are reviewed on a case‑by‑case basis.

• Submit the Drug Coverage Exception Form found on the payer website.
• Include supporting clinical documentation and the specific reason for the exception (e.g., prior therapy failure, contraindication, age exception).
• If an exception is granted it will be documented and applied to the member’s coverage; if denied, standard PA and cost‑sharing rules apply.