Please note: The forms on this page do not apply to our Affordable Care Act (ACA) plans. For ACA members, please call 855-811-2218 for more information.
*The medication names listed below may be the registered or unregistered trademarks of independent third-party pharmaceutical companies. These trademarks are included for informational purposes only and are not intended to imply or suggest any third-party affiliation.
Generic Program Exception Process
Some of our members have a Dispense as Written (DAW) generic program as part of their prescription drug benefits. This means if a member has a prescription for a particular brand-name drug that is also available in generic form, he or she will pay more for that brand-name drug if he or she opts to fill it instead of the generic version. If you feel that the generic version is not appropriate for a particular member, please complete this Generic Program Exception Form to request an exception detailing why this member must have the brand-name drug over the generic version. This exception process is only applicable to members whose benefits are subject to the rules under the ACA/essential health benefits for prescription drug coverage.
Nonspecialty Drug Prior Authorization Program
We require prior approval for drugs included in our prior authorization program for most members.
Our pharmacy benefit manager has partnered with CoverMyMeds to offer free electronic prior authorization (ePA) services to all providers and their staff. ePA helps prescribers and pharmacies quickly find, complete and submit prior authorization (PA) requests.
You can use CoverMyMeds to:
- Submit the request electronically
- Quickly find the correct PA request form for your patient’s plan
- Receive real-time plan specific clinical guideline questions (where applicable)
- Complete PA requests started by pharmacies
- Easily manage follow-up for all your requests and patients
- Check status of ePA requests submitted
To Get Started all you need to do is register for a free account or log into your existing CoverMyMeds account.
Create an account by:
- Clicking on the “Get Started” red button
- Filling out required basic account information:
- Full name
- Email address
- Office type
- Username and password
Our pharmacy benefit manager also accepts prior authorizations via phone and fax. To request prior authorization for non-specialty drugs, call the Prior Authorization department at 855-811-2218 (Commercial) or 855-540-5951 (Part D), or print the required prior authorization form and fax it to 844-403-1029 (Commercial) or 844-403-1028 (Part D).
These are fax forms for drugs in our prior authorization program:
- Amitiza, Motegrity-Trulence, Relistor
- Anticoagulant Agents
- Basaglar, Levemir, Tresiba
- Bydureon, BydureonBCise, Byetta
- Compounded Drugs
- Cumulative Morphine Equivalent Dose Exceptions
- Diabetic Test Strips
- DPP4 Inhibitors
- Freestyle Libre
- High Potency Statins
- Hypnotic Agents
- Lovaza, Omega 3 Acid Ethyl Esters, Vascepa
- Nasal Steroids
- Oral Fentanyl Products
- Overactive Bladder
- Prevacid Solutab, Lansoprazole ODT
- Riomet, Metformin Solution
- SGLT2 Inhibitors
- Soriatane, Acitretin
- Sporanox, itraconazole capsule
- Sporanox, itraconazole oral solution
PreCheck MyScript® is a real-time benefits check tool embedded within the EMR
workflow. It displays lower-cost alternatives for prescriptions, which medications
require prior authorizations (PAs), and more.
- Average savings for physicians and office staff for each PA that is avoided is $41.
- Average time savings for physicians and office staff for each PA that is avoided is 50 minutes
PreCheck MyScript seamlessly integrates with many common EMR platforms, with
additional integrations ongoing.
Quantity Management Program
We limit the amount we cover for medications included in the quantity management program for many members. We cover higher quantities for some medications, when medical necessity is documented.
Step Therapy Program
We require a generic or over-the-counter alternative trial before we cover medications included in the step therapy program for most members. We waive this requirement when medical necessity is documented.
More benefits of PreCheck MyScript:
- $225 average member savings per prescription switch
- Less faxing or calling for prior authorizations.
- Lower costs improve patient medication adherence and clinical outcomes.
- More time with patients and less administrative tasks.