Coverage Determination Request

The coverage determination process ensures that medication regimens that are high risk, have a high potential for misuse, or have narrow therapeutic indices are used appropriately and according to FDA-approved indications.

Providers may request an addition or exception for the following:

  • Drugs not listed in the formulary
  • Duplication of therapy
  • Prescriptions that exceed the FDA daily or monthly quantity limit
  • Most self-injectable and infusion medications
  • Drugs that have an age limit
  • Drugs included on the Preferred Drug List (PDL) that require prior authorization (PA)
  • Brand name drugs when a generic exists
  • Drugs that have a step therapy (ST) and the first-line therapy is inappropriate