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Coverage Determination

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

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Last Updated On: 5/25/2016