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Coverage Determination Request

The coverage determination process for prior authorization ensures that medication regimens that are high risk, have a high potential for misuse, or have narrow therapeutic indices are used appropriately and according to FDA-approved indications.

Please select and complete the appropriate coverage determination request:

Providers may request an addition or exception for the following:

  • Duplication of therapy
  • Prescriptions that exceed the FDA daily or monthly quantity limit
  • Drugs not listed on the PDL
  • Drugs that have an age edit
  • Brand name drugs when a generic exists


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Last Updated On: 9/14/2015
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