The coverage determination process 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 complete and submit a Coverage Determination Request if necessary.
Providers may request an exception for the following:
- Drugs not listed on the Preferred Drug List
- Duplication of therapy
- Prescriptions that exceed the FDA daily or monthly quantity limit
- Most self-injectable and infusion medications (including chemotherapy)
- Drugs that have an age limit
- Drugs included on the PDL that require prior authorization (PA)
- Brand name drugs when a generic exists
- Drugs that have a step therapy (ST) and the first-line therapy is inappropriate