Prior Approval

Helping you understand the prior approval process.

What is Prior Approval?

Some prescription drugs and supplies need approval before we cover them. This is known as prior approval. We need to confirm two things:

  • You’re using the drug to treat something we cover
  • Your doctor prescribes it in a medically appropriate way

We require prior approval if the drug:

  • May be used outside the Food & Drug Administration or drug maker’s guidelines
  • Requires you to have tests to make sure the drug is effective for you
  • May be used to treat conditions or illnesses we do not cover
  • Has unique dosing and/or administration requirements
  • Is known to have bad side-effects and/or to be abused

You can view the current prior approval list here. We review and update the list often.

How to Obtain Prior Approval

There are three ways to get Prior Approval:

  1. Your doctor can submit an electronic prior approval
  2. Your doctor can  call us toll-free at 1-877-727-3784 between 7 a.m. and 9 p.m. Monday through Friday, Eastern time. This phone number is only for doctor’s offices.
  3. Your doctor can submit a paper prior approval.  You can download a form on the Prior Approval Page.

Questions?

If you have questions about this process, please call the Retail Pharmacy Program toll-free at 1-800-624-5060.