Prior authorization required for all listed drugs

All drugs listed in this policy require prior authorization (PA). Submit the PA to the reviewer specified for the drug (ESI, CCUM, eviCore, or WPS). If the listed reviewer cannot complete the review, submit the request to WPS for evaluation.

• Applies to every drug on the list — PA is required before coverage is approved.
• Use the vendor assignment shown next to each drug entry (ESI, CCUM, eviCore) or WPS if the vendor cannot complete the review.

Submit PA to alternate PBM/vendor when applicable

When the group uses an alternate PBM or vendor (not ESI/CCUM/eviCore), submit prior authorization requests to the applicable PBM/vendor and follow that vendor's precertification process.

• Includes pharmacy drugs reviewed by ESI or eviCore — submit to the other PBM when applicable.
• If the external vendor cannot complete the review, escalate submission to WPS for evaluation.

Obtain PA and submit to designated reviewer

Prior authorization must be obtained for every drug on the list and routed to the reviewer indicated for that specific drug (ESI, CCUM, or eviCore). If the designated PBM cannot complete the review, submit to WPS.

• Use the reviewer contact shown in the drug entry (vendor phone numbers provided).
• Coverage is contingent on PA approval by the designated reviewer.

Follow reviewer routing and use provided contact numbers

Prior authorization is required for each listed drug; the policy shows which reviewer handles each drug and provides reviewer phone numbers for submission. If the vendor cannot complete the review, submit to WPS.

• Reviewer assignments (ESI, CCUM, eviCore or WPS) are provided per drug entry with contact lines.
• Follow the reviewer routing noted in the drug listing when submitting PA requests.

Include HCPCS/CPT codes and route PA to named reviewer

A prior authorization is required for each product listed; the document supplies HCPCS/CPT or miscellaneous codes and identifies the designated reviewer to which the PA must be routed.

• Include the HCPCS/CPT or J-code listed for the product when preparing the PA submission.
• Route the request to the reviewer named in the drug entry (ESI, CCUM, eviCore, or WPS).

Submit PA to the designated reviewer (or WPS if vendor unavailable)

Submit prior authorization requests to the reviewer indicated for the drug. If the indicated reviewer cannot complete the review, submit the PA to WPS for evaluation using the WPS provider contact.

• Use the vendor phone number listed in the drug entry (e.g., 1-800-475-1954 for ESI/CCUM/eviCore).
• If vendor review cannot be completed, submit to WPS at 1-800-333-5003.

Submit PA to the reviewer listed for that drug

Prior authorization must be submitted to the reviewer identified for that drug entry (ESI, CCUM, eviCore or WPS); follow the reviewer assignment shown in the policy.

• Reviewer assignment and the HCPCS/J-code are shown for each drug — submit both as part of the request.
• If the reviewer cannot complete the review, escalate the request to WPS.

Use reviewer assignment and HCPCS codes from drug entry

Each listed drug requires prior authorization; the policy lists reviewer assignments and HCPCS/J-codes per product — submit the PA to the reviewer shown for that code.

• Include benefit type (P or M) and the HCPCS/J-code in the PA submission per the drug entry.
• Route to ESI, CCUM, or eviCore as indicated; if those reviewers cannot complete the review, submit to WPS.

Route PA by benefit type to the reviewer indicated

The policy lists benefit type and the reviewer routing for each drug. Submit PA requests to the reviewer shown (ESI, CCUM, or eviCore) according to the drug’s benefit type and routing instruction.

• Benefit Type indicates Pharmacy (P) or Medical (M) — use this when determining submission process.
• If external reviewer cannot complete review, submit to WPS for evaluation.

If PBM reviewer cannot complete review, submit to WPS

If the PBM for the group is unavailable or unable to complete the review, route the prior authorization request to the appropriate vendor (ESI, CCUM, eviCore) or submit directly to WPS for evaluation.

• Primary vendor phone line for ESI/CCUM/eviCore: 1-800-475-1954.
• WPS provider contact for escalation: 1-800-333-5003.

Contact designated reviewer or submit per routing instructions

All drugs on this list require prior authorization; contact the designated reviewer via the vendor phone number listed in the drug entry or submit per the routing instructions in the policy.

• Use vendor contact 1-800-475-1954 for ESI/CCUM/eviCore.
• If vendor cannot complete the review, submit the PA to WPS at 1-800-333-5003.

Submit PA for listed HCPCS/CPT codes to assigned reviewer

Prior authorization is required for the HCPCS/CPT codes listed with each drug; submit PA to ESI, CCUM, or eviCore as indicated, and use WPS if the PBM cannot complete the review.

• Include the HCPCS/J-code shown in the drug entry when requesting PA.
• Route to the reviewer indicated (CCUM, ESI, eviCore); escalate to WPS if needed.

Submit PA to assigned reviewer; escalate to WPS if needed

Reviewer assignment is indicated for each drug; submit prior authorization requests to the assigned reviewer (ESI, CCUM, eviCore) and use WPS as the escalation path if the reviewer cannot complete the review.

• Reviewer phone numbers for vendors and WPS are provided in the document.
• Follow the per‑drug reviewer assignment when submitting PAs.

Submit to designated reviewer; WPS accepts submissions if PBM cannot complete review

Submit the prior authorization to the reviewer shown for that drug entry; if the PBM reviewer is unable to complete the review, WPS will accept the submission for evaluation.

• Use the reviewer assignment (e.g., CCUM option 2 for certain products) shown next to the drug.
• When vendor review cannot be completed, submit to WPS at 1-800-333-5003.

Submit PA to indicated reviewer; include supporting clinical information

Prior authorization must be submitted to the reviewer indicated for the drug (ESI, CCUM, or eviCore). If those reviewers cannot complete the review, submit the PA to WPS for evaluation.

• Provide the drug name and supporting clinical information with the PA submission.
• Use the vendor phone numbers provided in the policy when contacting external reviewers.

Submit PA with clinical support to designated reviewer or WPS

Submit prior authorization requests to the reviewer identified for the drug; if the PBM cannot complete the review, submit to WPS for evaluation using the WPS contact information provided.

• Include the HCPCS/J-code and clinical justification (medical records, prior treatments, FDA labeling) when submitting PA.
• If using a PBM other than ESI through WPS, submit to that PBM per the group’s arrangement.

Call 1-800-475-1954 for step therapy or PA criteria

Providers may obtain detailed step therapy or prior authorization criteria by calling the prior authorization specialist at 1-800-475-1954 for drugs reviewed by Express Scripts or Care Continuum.

• Call 1-800-475-1954 to speak with a prior authorization specialist for step therapy or PA requirements.
• For eviCore step-therapy/guideline details, consult eviCore’s provider clinical guidelines online.

No step therapy rules specified in this excerpt

The policy does not provide step therapy algorithms or specific step requirements in the listed excerpts.

• No explicit step therapy rules are specified in this document segment; follow PBM/vendor guidance or contact the prior authorization specialist for details.

Note — limited excerpt

(No additional requirements specified in this excerpt.)

Follow oncology vs non‑oncology reviewer routing

Some oncology biologics show different reviewer routing for oncology versus non-oncology use (e.g., CCUM for non-oncology, eviCore for oncology); follow the routing in the drug entry when submitting PAs.

• Check the drug’s comments for routing differences by indication (oncology vs non‑oncology).
• Submit to eviCore for oncology indications when indicated; submit to CCUM/ESI for non‑oncology as shown.

Step therapy not specified — follow vendor guidance

Step therapy is not defined in these chunks; the policy reiterates PA routing instructions without specifying step-therapy steps.

• If step therapy is required, contact the prior authorization specialist or the assigned PBM for details.
• Do not assume step therapy rules from this excerpt; use vendor guidance.

No step therapy rules in this segment

No step therapy rules or additional PA routing beyond reviewer assignments are provided in this segment.

No step therapy rules provided

No step therapy rules are provided in these chunks; the policy focuses on PA requirement and reviewer routing.

Step therapy not specified here

No step therapy rules are specified in these chunks; submit PAs per PBM routing instructions.

Step therapy not specified in provided chunks

No step therapy rules are specified in the provided segments of the policy.

Follow per‑drug reviewer/program assignment

Reviewer routing and program assignment differ for some products — e.g., certain drugs route to eviCore for oncology reviews and to CCUM or ESI for non‑oncology; follow the routing shown per drug entry.

• Confirm indication in the patient's record to determine correct reviewer routing.
• If the reviewer indicated cannot complete the review, submit to WPS.

Submit PA to other PBM when group does not use ESI through WPS

If the group uses a PBM other than ESI through WPS, submit the PA to that PBM for review (this includes pharmacy drugs that would otherwise be reviewed by ESI or eviCore under WPS arrangements).

• Follow the alternate PBM’s precertification process and contact information.
• If the alternate PBM cannot complete the review, escalate to WPS for evaluation.

Submit PA to other PBM when applicable

If the sponsor uses a different PBM, submit PA requests to that PBM rather than the ESI/CCUM/eviCore contacts listed in this policy.

Provide medical records and supporting clinical information with PA

Decision-makers use the patient’s medical records, prior treatments, FDA labeling, and peer‑reviewed literature as supporting documentation during PA review — include these when submitting a request.

• Provide relevant medical records and prior treatment history.
• Include FDA labeling and any supporting literature or evidence-based guidelines where applicable.

Submit PA to the listed reviewer or escalate to WPS

Submit PA requests to the reviewer listed in the drug entry using the vendor phone numbers provided; if the vendor cannot complete the review, submit the PA to WPS for evaluation.

• Use vendor contact 1-800-475-1954 for ESI/CCUM/eviCore.
• If vendor review cannot be completed, submit to WPS at 1-800-333-5003.

Escalate to WPS when vendor cannot complete review

When PBMs (ESI, CCUM, eviCore) cannot complete the review, submit the PA to WPS; if the group uses another PBM, submit to that PBM per group arrangement.

• If using another PBM, follow its submission process (e.g., iExchange or fax form per WPS instructions).
• WPS will evaluate requests when external reviewers cannot complete reviews.

Submit PA to listed reviewer or to WPS if PBM cannot complete review

Provide the prior authorization request to the reviewer listed for the drug (ESI, CCUM, or eviCore) or to WPS if the PBM cannot complete the review; reviewer phone numbers are provided in the policy.

• Include the drug name, HCPCS/J-code, benefit type and clinical justification in the submission.
• Use vendor phone numbers or WPS contact for submission and escalation.

Submit PA to designated reviewer or WPS when necessary

Submit PA to the designated reviewer shown for the drug or to WPS if the PBM reviewer cannot complete the review; WPS accepts submissions for evaluation.

• Use the reviewer and escalation contact numbers listed in the drug entry.
• If the group uses an alternate PBM, submit to that PBM per the group's arrangement.

Use ESI/CCUM/eviCore routing; escalate to WPS if required

Submit PA to ESI, CCUM, or eviCore according to the reviewer routing shown for each drug; if those reviewers cannot complete the review, submit the PA to WPS for evaluation.

• Follow the per‑drug reviewer assignment shown in the policy.
• Escalate to WPS using the provided contact when external reviewers cannot complete review.

Submit to WPS when vendor cannot complete review; follow alternate PBM guidance

When external reviewers cannot complete the PA review, submit the prior authorization request to WPS for evaluation; if the group uses another PBM, submit to that PBM as appropriate.

• WPS contact for escalations: 1-800-333-5003.
• For groups not using ESI through WPS, use the alternate PBM’s submission process (iExchange or PA form fax).

Submit PA to designated reviewer; include clinical support

Submit the prior authorization request to the reviewer indicated in the drug entry; if reviewers cannot complete the review, submit to WPS using the WPS contact number provided.

• Provide drug name and supporting clinical documentation when submitting the PA.
• Follow the reviewer phone contacts listed in the policy for initial submission.

Submit PA to WPS if vendor cannot complete review

If a PBM cannot complete the review, submit the PA request to WPS for evaluation using the contact provided in the policy.

• WPS contact for evaluation: 1-800-333-5003.
• If external reviewer cannot complete review, WPS will accept the submission for evaluation.

Submit to vendor reviewers or escalate to WPS

Submit PA requests to the listed reviewer (ESI, CCUM, or eviCore) per the reviewer routing; when reviewers cannot complete review, submit to WPS for evaluation and use the phone contacts provided.

• Use the reviewer phone number 1-800-475-1954 for vendor submissions.
• Escalate to WPS at 1-800-333-5003 if external vendors cannot complete the review.

Provide drug and clinical info and submit PA to reviewer or WPS

Submit the prior authorization to the reviewer shown for the drug or to WPS if the PBM cannot complete the review; reviewer phone numbers and WPS contact are provided in the policy.

• Provide drug name, HCPCS/J-code and supporting clinical information with the PA submission.
• If the group uses an alternate PBM, submit to that PBM per their process.

Submit to assigned vendors; escalate to WPS when needed

Submit PA to ESI, CCUM, or eviCore as listed; if those reviewers cannot complete the review, submit the PA to WPS for evaluation using the contact information supplied.

• Follow per‑drug reviewer routing; include clinical documentation.
• Use WPS contact 1-800-333-5003 for escalations when external reviewers cannot complete review.

Submit PA to listed reviewer or alternate PBM; escalate to WPS if needed

Submit the prior authorization to the listed reviewer (ESI, CCUM, or eviCore) or to WPS if those reviewers cannot complete the review. If the plan uses a PBM other than ESI through WPS, submit to that PBM.

• If using another PBM, follow that PBM’s submission process (iExchange or PA form fax options noted in the policy).
• When vendor reviews cannot be completed, WPS will accept the submission for evaluation.

Submit PA to listed reviewer; escalate to WPS if reviewer cannot complete

Submit PA to the vendor listed for the drug; if the external reviewer is unable to complete the review, submit the PA to WPS for evaluation using the WPS contact number.

• Include HCPCS/J-code and clinical justification in the submission.
• WPS escalation contact: 1-800-333-5003.

Include drug name and supporting clinical documentation with PA

Provide the drug name and supporting clinical information (medical records, prior treatments, FDA labeling, literature) when submitting PA to the listed reviewer (ESI, CCUM, eviCore) or to WPS if the PBM cannot complete review.

• Medical records and prior treatment history should be included.
• Cite FDA labeling or peer‑reviewed literature when relevant to support medical necessity.

Coverage subject to medical necessity; investigational services not covered

Coverage is subject to medical necessity; services deemed experimental, investigational, and/or unproven will not be covered.

• Ensure documentation supports medical necessity and is consistent with evidence‑based guidelines.
• Requests for experimental or investigational uses may be denied.

Denial risk if PA not obtained

Failure to obtain prior authorization for any drug on this list may result in denial of coverage.

• All drugs listed require PA prior to coverage.
• Claims submitted without an approved PA may be denied or processed as non‑authorized.

Claims may be denied without PA

All drugs on this list require prior authorization; claims submitted without PA may be denied.

• PA must be approved by the designated reviewer for coverage to be authorized.
• If the reviewer cannot complete the review, submit to WPS to avoid denial risk.

Claim denial risk if PA not submitted

Failure to submit a prior authorization for any drug on the list may result in denial of coverage because all drugs listed require a PA.

• Submit PA before dispensing or administration to avoid claim denial.
• When in doubt, submit to the designated reviewer or escalate to WPS.

Requests denied if PA not obtained

All drugs on this list require PA; requests will be denied if prior authorization is not obtained.

• Do not administer or dispense listed drugs without PA approval when coverage is sought from WPS.
• Use vendor or WPS submission routes provided to obtain authorization.