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Pharmacy prior authorization guidelines

Our decision-making process

Some medications on our formulary need prior authorization before they can be dispensed. First, you’ll request prior authorization for a member’s medication. Then, we’ll review your request and make our decision using the Department of Health Care Services’ prior authorization guidelines as well as our own custom guidelines.

 

Here are some of the guidelines that we use in our decision making:

 

For more information

If you have questions or would like a copy of these guidelines sent to you, call Provider Relations at 1-855-772-9076 (TTY: 711).