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- Prescription Drug Prior Authorization List
Certain drugs may require a prior authorization in order to receive the prescription (or the full quantity) your doctor prescribes.
If you or your doctor feels there are circumstances that require greater quantities of medication than the Plan allows, your doctor may request a coverage review. For some drugs, more information than what is provided on a prescription form (or from the pharmacy) is needed to determine if coverage for additional medication can be provided. The prescribing doctor can provide additional information for the coverage review by calling toll-free 1.800.753.2851, Monday through Friday, 8:00 a.m. to 9:00 p.m., Eastern Time.
The following list identifies the brand names or categories of the drugs that may require prior authorization. It is subject to change at any time.
| Anti-emetics | PPIs (Nexium, Prilosec, etc.) |
| Cox-2's (Celebrex) | Narcolepsy agents |
| Erythroid cell boosters | Psoriasis |
| Herpes antivirals | H2's (Axid, Pepcid, etc.) |
| Hypnotics | Retin-A |
| IBS agents (gastrointestinal medications) | Rheumatoid arthritis |
| Leukotriene agents (allergy medications) | Wellbutrin SR |
| Migraine drugs | White cell boosters |
| Multiple sclerosis drugs | Xolair |
If the prior authorization request is denied, or the quantity and/or dosage that the doctor prescribed is not approved, you should contact Medco at 1.800.753.2851 for instructions on how to appeal this decision.
Note: Every attempt has been made to ensure the accuracy of this summary. However, its contents are not legally binding nor should it be considered as a substitute for the actual contract language, company policies, or Book of Benefits