Drug Coverage Policies

Below are links to our policies relating to drug coverage, including limitations, criteria for coverage, and treatment guidelines.

Requires Prior Authorization

  • Benzodiazepines
  • Botulinum toxin
  • Buprenorphine and buprenorphine/naloxone transmucosal
  • Buprenorphine transdermal
  • Calcitonin Gene-Related Peptide (CGRP) Receptor Antagonists for Migraine Prophylaxis
  • Compounded drug products
  • Direct-acting antivirals for hepatitis C
  • Drug Therapy for Acute Treatment of Migraine Headache
  • Drug therapy for neuropathic pain
  • Hyaluronic acids or viscosupplementation
  • Opioids for non-cancer pain
  • Phosphodiesterase-5 (PED5) inhibitors quantity limit for erectile dysfunction
  • Tobacco cessation for surgical care
  • Tramadol

Not Covered

  • Carisoprodol
  • Fentanyl transdermal
  • Lidocaine infusion for chronic pain
  • Medical Foods and "co-pack" products
  • Opioid transmucosal
  • Sedative-hypnotics