Prior Authorization Forms and Clinical Guidelines
If you believe that it is medically necessary for a member to take a medication excluded by our pharmacy program, and you have followed the procedures required by our pharmacy programs, please select the member's plan below. Then locate the preferred drug and send its prior authorization form to us.
The Plan defines medically necessary services as those services:
- Which are reasonably calculated to prevent, diagnose, prevent the worsening of, alleviate, correct, or cure conditions in the member that endanger life, cause suffering or pain, cause physical deformity or malfunction, threaten to cause or to aggravate a disability, or result in illness or infirmity; and
- For which there is no other healthcare service or site of service, comparable in effect, available, and suitable for the member requesting the service that is more conservative or less costly. Medically necessary services must be of a quality that meets professionally recognized standards of health care, and the services must be substantiated by records that include evidence of such medical necessity and quality.