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Coverage Determination

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

The coverage determination process is required for:

  • Duplication of therapy
  • Prescriptions that exceed the FDA daily or monthly quantity limit
  • Most self-injectable and infusion medications (including chemotherapy)
  • Drugs not listed on the PDL
  • Drugs that have an age edit
  • Drugs listed on the PDL but still require Prior Authorization (PA)
  • Brand name drugs when a generic exists
  • Drugs that have a step therapy edit and the first-line therapy is inappropriate