Policies & Forms

For the medical criteria of the below policies, please refer to the Medical Policy manual.

Please refer to the Drugs Requiring Preauthorization list for our standard list of medications requiring preauthorization.  Additional medications may require preauthorization per individual contract. Please refer to the Medical Policy manual for those policies and medications. You may also refer to our Outpatient Drug Exclusions List for members.

Note: Starting Oct. 1, 2015, please submit requests using the appropriate ICD-10 codes.

Pre-Authorization Forms


Specialty Drug Benefits