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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 Maryland Department of Health’s prior authorization guidelines as well as our own custom guidelines. 


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

Hepatitis C guidelines

Hepatitis C therapy prior authorization form (PDF)


You can find more information on the Maryland Department of Health’s website, including their:


  • Hepatitis C clinical criteria  
  • Hepatitis C sample enhanced treatment plan  
  • Hepatitis C sample treatment plan  

For more information

If you have questions or would like a copy of these guidelines sent to you, call Provider Relations at 1-866-827-2710 (TTY: 711).