Pharmacy Clinical Policy | Pre-certification | Prior Authorization

New FDA approved provider administered drugs may be non-covered until a full internal review has occurred, which may take up to 180 days. See Pharmacy Policy PP/R001.

Medications that are being used outside their FDA approved dose, indication, or frequency require review in accordance with our off-label policy PP/O001.

Medications that are being used outside their FDA approved dose, indication, or frequency require review in accordance with our off-label policy PP/O002.

*Site of Care Criteria Applies (MC/K003) Site of Care List.pdf

View Prior Authorization List here:

Prior Authorization List Prior Authorization List