Prior authorization required for all listed drugs

All drugs listed require prior authorization before coverage will be approved. If ESI, CCUM, or eviCore cannot complete the review, submit the request to WPS for evaluation; if the group's PBM differs from ESI, submit to that PBM as instructed.

• PLEASE NOTE: All drugs on this list require a PA.
• If ESI, CCUM, or eviCore cannot complete the review, submit to WPS for evaluation.
• If using a PBM other than ESI through WPS, submit to the other PBM.

Network-specific PA submission rules (AETNA/Auxiant groups)

For WPS Powered by Auxiant groups using the AETNA Network, pharmacy benefit drugs require prior authorization through Express Scripts, eviCore, or WPS as indicated; medical benefit drugs do not require PA but a medical necessity review is recommended and notes should be faxed to American Health Holdings (AHH) as instructed.

• Pharmacy Benefit (P): PA required via ESI, eviCore, or WPS as indicated.
• Medical Benefit (M): PA not required; perform medical necessity review and fax notes to AHH at 608-273-4554.

Submit PA to designated PBM/reviewer

Submit prior authorization requests to the PBM or reviewer shown for each drug; if the PBM in use is not ESI, submit to that PBM per the listing.

• Follow the reviewer assignment in the per‑drug entry (ESI, CCUM, eviCore, or WPS).
• If the PBM differs from ESI, submit to the other PBM for pharmacy‑benefit drugs.

PA required; delegated reviewers perform reviews

All drugs on the published list require prior authorization; reviews are performed by delegated reviewers (ESI, CCUM, eviCore) as indicated for each drug or submitted to WPS if those reviewers cannot complete the review.

• Per‑drug entries list the designated reviewer; submit requests there first.
• If external reviewer cannot complete the review, submit to WPS for evaluation.

Routing: use indicated PBM/reviewer or escalate to WPS

If you use a PBM other than ESI, submit the PA to that PBM for drugs they review; if ESI, CCUM, or eviCore cannot complete the review, submit the request to WPS for evaluation.

• Submit to the PBM/reviewer indicated in the per‑drug 'Reviewer' field.
• Fallback: submit to WPS when the external reviewer cannot complete the review.

PA required — include HCPCS/J‑codes and reviewer

Prior authorization is required for the listed drugs; many entries include HCPCS/J‑codes and identify the reviewer organization that will process the PA request.

• Include the HCPCS/J‑code shown in the per‑drug entry with your PA submission.
• Use the reviewer assignment (ESI, CCUM, eviCore, or WPS) for routing.

Route PA to reviewer listed in column 4

Submit prior authorization requests following the reviewer assignment shown in column 4 of each drug entry (ESI, CCUM, eviCore, or WPS); that reviewer will handle the PA processing.

• Column 4 of each entry lists the designated reviewer and option number (e.g., ESI option 1, CCUM option 2, eviCore option 3).
• If the designated external reviewer cannot complete the review, submit to WPS.

PA required — include benefit type and HCPCS/admin codes

Prior authorization is required for each listed drug; per‑drug entries include the benefit type (P = Pharmacy, M = Medical) and HCPCS/administration codes which should be used for billing and submission.

• Reference the Benefit Type field (P or M) and HCPCS code in PA requests and claims.
• Use the reviewer specified in the per‑drug record (ESI, CCUM, eviCore, or WPS).

PA required — reviewer assigned with contact routing

All drugs listed require prior authorization; the document identifies the responsible reviewer (ESI, CCUM, eviCore, or WPS) and provides contact/routing instructions.

• Reviewer phone routing is provided in the Description, 4 field (ESI/CCUM/eviCore: 1‑800‑475‑1954; WPS: 1‑800‑333‑5003).
• Follow the per‑drug reviewer assignment to determine where to submit the PA.

Submit to indicated PBM/reviewer or escalate to WPS

Submit the PA to the PBM or reviewer indicated for the drug; if that reviewer cannot complete the review, submit to WPS for evaluation.

• Designated reviewers include ESI, CCUM, eviCore (option numbers shown) or WPS.
• Contact numbers are provided for vendor reviewers and WPS for escalation.

Each drug mapped to benefit type, HCPCS/J‑codes, and reviewer

Prior authorization is required for the listed drugs; the table associates each drug with benefit type, one or more HCPCS/J‑codes, and the designated reviewer responsible for the PA.

• Per‑drug entries show Alt Descriptions, Benefit Type, HCPCS Code, Reviewer, and Drug Comments.
• Providers should reference these fields when preparing PA submissions.

Submit PA to specified reviewer; fallback to WPS if needed

Submit prior authorization requests to the specified reviewer shown for each drug; if that reviewer cannot complete the review, submit to WPS for evaluation.

• If using a PBM other than ESI through WPS, submit to that PBM as instructed.
• Fallback to WPS when delegated reviewers cannot complete the review.

Route PA to listed reviewer using provided contact avenues

All drugs require prior authorization and submissions should be routed to the reviewer listed (ESI, CCUM, eviCore or WPS) based on the per‑drug 'Reviewer' field; use vendor contact avenues provided.

• Reviewer assignments determine routing; eviCore commonly handles oncology agents.
• Contact numbers and submission channels are provided in the per‑drug entries.

PA required — HCPCS codes and reviewer assignment included

Prior authorization is required for all drugs listed; each entry provides HCPCS/HCPCS‑like codes and assigns the reviewer (ESI, CCUM, eviCore, or WPS) to process the PA.

• Include the HCPCS/HCPCS‑like code from the per‑drug entry in PA and billing documentation.
• Submit to the reviewer assigned in the drug entry.

Submit PA to designated reviewer or PBM; escalate to WPS if needed

Submit the PA to the reviewer/PBM indicated for the drug (ESI, CCUM, eviCore); if they cannot complete the review, submit to WPS. If your group uses a PBM other than ESI through WPS, submit to that PBM.

• Designated reviewers and PBM routing are shown for each drug entry.
• WPS serves as the escalation path when delegated reviewers cannot complete review.

Escalate PA to WPS when external reviewer cannot complete review

If an external reviewer (ESI, CCUM, eviCore) cannot complete the review, submit the prior authorization request to WPS for evaluation; providers should follow the submission instructions for the designated reviewer first.

• Submit to the per‑drug reviewer initially; escalate to WPS when review cannot be completed externally.
• WPS contact number is provided for escalation.

Where to obtain PA and step‑therapy criteria

Step therapy and prior authorization criteria for drugs reviewed by Express Scripts or Care Continuum are available by calling 1-800-475-1954; eviCore criteria are available at evicore.com and gene therapy coverage should be confirmed with WPS Customer Service.

• Express Scripts / Care Continuum PA/step therapy: call 1-800-475-1954.
• eviCore clinical guidelines: https://www.evicore.com/provider/clinical-guidelines (search for 'WPS Health Insurance').
• Confirm Gene Therapy coverage with WPS Customer Service (member card number).

Step therapy not specified in this section

Per‑drug entries generally do not specify step therapy algorithms in this section; many entries include reviewer routing or 'see comments' rather than explicit step therapy steps.

• Some entries show 'see comments' or reviewer‑specific notes that may indicate additional utilization management handled by the reviewer.
• No explicit step therapy sequences or required prior failures are provided in these chunks.

No explicit step therapy rules in per‑drug listings

This section does not include explicit step therapy rules; per‑drug reviewer routing and comments are provided instead and may indicate reviewer‑specific requirements.

• Entries with 'see comments' may reflect additional utilization management by the assigned reviewer.
• Providers should consult the reviewer or the contact listed for specific PA/step therapy criteria.

Follow reviewer comments for additional requirements

Some per‑drug entries include 'see comments' which indicates that additional reviewer‑specific or drug‑specific requirements may apply; providers should follow reviewer guidance for those items.

• When 'see comments' appears, consult the designated reviewer (ESI/CCUM/eviCore) for any additional submission requirements.
• Reviewer may require supporting documentation or different routing depending on drug specialty.

Documentation used in PA reviews — supply medical records and references

Medical records describing the patient's condition and prior treatments, FDA labeling, peer‑reviewed literature, and evidence‑based guidelines are used during PA review and should be made available to reviewers.

• Provide medical records and prior treatment history with PA requests when relevant.
• Reviewers will reference FDA labeling and clinical literature in coverage determinations.

Where to submit prior authorization requests

Submit PA requests to the listed reviewer (ESI, CCUM, eviCore) shown for each drug; if the third‑party reviewer cannot complete the review, submit to WPS using the contact information provided.

• Reviewer contact avenues and option numbers are provided in Description, 4 of each entry.
• WPS contact provided for escalation when vendor reviewers cannot complete review.

Include HCPCS/billing code and benefit type on PA submissions

Include the per‑drug HCPCS/ billing code and benefit type (P = Pharmacy, M = Medical) when submitting PA requests so the reviewer can correctly route and process the request.

• Description fields: 1 = Alt Descriptions; 2 = Benefit Type; 3 = HCPCS Code; 4 = Reviewer; 5 = Drug Comments.
• Providers should supply the HCPCS/J‑code and benefit type from the per‑drug entry on the PA request.

Use listed HCPCS/J‑codes and reviewer contacts for submissions

Reference the HCPCS/J‑codes and benefit type listed for each drug when preparing claims or PA submissions and use the reviewer contact numbers if clarification or additional information is needed.

• Per‑drug entries include HCPCS/HCPCS‑like codes to be used for billing and routing.
• Use the reviewer phone numbers shown in the document for submission or questions.

Provide per‑drug description fields with PA requests

Each drug entry contains fields (alternate description, benefit type, HCPCS code, reviewer, drug comments); providers should supply this information with PA requests to ensure accurate routing and review.

• Description, 1 = Alt Descriptions; 2 = Benefit Type; 3 = HCPCS Code; 4 = Reviewer; 5 = Drug Comments.
• Providing all fields reduces delays and supports reviewer evaluation.

Submit PA to the designated reviewer using provided contacts

The table provides HCPCS/administrative codes and the designated reviewer to contact (ESI, CCUM, eviCore, or WPS) for PA processing; contact numbers are listed for reviewers and WPS for escalation.

• Submit to the designated reviewer indicated in the per‑drug entry.
• If the designated reviewer cannot complete review, use WPS contact for escalation.

Use benefit type and HCPCS codes for billing and routing

Per‑drug entries include benefit type and HCPCS codes that should be used for billing and reviewer routing; include the appropriate HCPCS/J‑code and benefit type when submitting the PA.

• Benefit Type: P = Pharmacy, M = Medical.
• Include the HCPCS/J‑code listed in Description, 3 on PA forms and claims.

Designated reviewer submission and escalation contacts

Submit PA requests to the designated reviewer (ESI, CCUM, or eviCore) shown for each drug; if those reviewers cannot complete the review, submit to WPS for evaluation. Contact numbers for ESI/eviCore (1‑800‑475‑1954) and WPS (1‑800‑333‑5003) are provided.

• ESI/eviCore phone: 1‑800‑475‑1954.
• WPS phone for escalation: 1‑800‑333‑5003.

Use reviewer routing and contact info from the table

Reviewer contact information and reviewer assignment are provided in the per‑drug entries; submit PA to the listed reviewer (ESI, CCUM, eviCore) or to WPS if external reviewers cannot complete the review.

• Reviewer assignments appear in Description, 4 for each drug entry.
• Use the provided phone numbers for submission or questions.

Required documentation elements for PA submission

Each drug entry includes alternate descriptions, benefit type (P = Pharmacy), HCPCS/billing code, reviewer assignment (ESI, CCUM, eviCore, or WPS) and drug comments; providers should submit PA requests to the assigned reviewer or to WPS if the reviewer cannot complete the review.

• Include alternate description and HCPCS code to ensure correct review routing.
• Follow reviewer assignment; escalate to WPS when necessary.

Reviewer routing and escalation contact information

Reviewer contact routing is provided: ESI, CCUM, and eviCore have phone numbers for submission and WPS is the escalation contact when external reviewers cannot complete review.

• Use vendor reviewer contact for initial submission; escalate to WPS if vendor cannot complete review.
• Reviewer contact numbers are included in the per‑drug entries.

Route PA to listed reviewer; use WPS if vendor cannot complete review

PA submissions should be routed to the listed reviewer per drug (ESI, CCUM, eviCore or WPS) using the provided contact numbers when a vendor cannot complete the review.

• Submit to the reviewer indicated in the per‑drug 'Reviewer' field.
• When the reviewer cannot complete the review, submit to WPS using the escalation contact.

Submit PA to designated reviewer/PBM with required codes

Providers must submit PA requests to the designated reviewer/PBM listed for each drug (ESI, CCUM, eviCore, or WPS) using the contact avenues noted; include the HCPCS/billing code and benefit type from the per‑drug entry.

• Designated reviewer is shown in each entry; use their contact channel for PA submission.
• Include HCPCS code and benefit type to avoid processing delays.

Reviewer contact numbers and submission routing for escalation

Reviewer contact numbers and reviewer assignment (ESI, CCUM, eviCore, or WPS) are provided for submission if external reviewers cannot complete the review; use these contacts for escalation.

• Contact numbers for reviewers and WPS are provided in the document.
• Escalate to WPS when delegated reviewers cannot complete review.

Denial risk for experimental/investigational services

Services deemed experimental, investigational, and/or unproven under clinical guidelines will not be covered and may be denied; ensure requested use aligns with accepted clinical guidance.

• Requests for indications considered experimental, investigational, or unproven may be determined not medically necessary and denied.
• Provide supporting clinical evidence when requesting coverage for non‑standard uses.

Denial risk if PA not obtained for listed drugs

Failure to submit a prior authorization for any drug on this list may result in denial or deferral of coverage because the policy states that all drugs on the list require a PA.

• PLEASE NOTE: All drugs on this list require a PA.
• Claims for listed drugs may be denied if PA is not obtained and submitted to the listed reviewer.