Clinical Pharmacy and Specialty Drugs Prior Authorization ...

Medications may be covered when they are FDA-approved for specific diagnoses and deemed medically necessary based on clinical appropriateness. Prior authorization is required for certain specialty drugs and outpatient services, with the necessity to trial lower-cost alternatives first in some cases. Limitations include potential denial of coverage if clinical criteria are not met, quantity duration limits, and requirements for additional documentation to determine eligibility.

"Medications may be covered when they meet FDA approved uses and medication labeling based on specific diagnosis."

Sign up to see full coverage criteria, indications, and limitations.