Rx PA Drug Treatment Criteria
Prescription Drug Prior Authorization (Rx PA) Drug Treatment Criteria
For Medicare Dual Choice Cal MediConnect Plan (Medicare-Medicaid Plan) Formulary and Criteria information, please visit the page here:
Medicare Dual Choice Cal MediConnect Plan - Click Here
To provide access to quality and clinically effective medications, IEHP uses a drug formulary. The IEHP Formulary provides information regarding medications covered under the benefit plans.
Please note that coverage is not limited only to drugs on the IEHP Formulary. Many drugs not listed on the Formulary are covered through the Rx Prior Authorization Process.
- Rx prior authorization encourages the appropriate and rational use of medications by allowing coverage only when certain conditions are met.
- The Rx prior authorization program is based upon current medical findings, FDA-approved manufacturer labeling information, and recommendation by the IEHP Pharmacy and Therapeutics Subcommittee.
- If the medication you prescribe is not on IEHP Formulary, you or the pharmacist may request authorization for the medication by submitting an IEHP Prescription Drug Prior Authorization Request Form (Rx PA) to IEHP. If the request is approved, you will be notified and the medication will be covered. If the request is denied, you and your patient will be notified of the decision.
Any medication not on the IEHP Formulary requires Rx Prior Authorization to be covered by IEHP.
The medications requiring Rx Prior Authorization are subject to change.
First line Formulary medications should be used instead of the Non-Formulary medications. Drugs with specific criteria / guidelines are listed here:
You will need Adobe Acrobat Reader 6.0 or later to view the PDF files. You can download a free copy by clicking here. By clicking on this link, you will be leaving the IEHP website.
Drug Prior Authorization Criteria
Drug Class Prior Authorization Criteria
- Adult Enteral Nutritional Supplement (PDF)
- Antineoplastic Agents (PDF)
- Botulinum Toxin (PDF)
- Erythorpoieses-Stimulating Agents (PDF)
- Growth Hormones (PDF)
- Hepatitis C (PDF)
- Hereditary Angioedema (PDF)
- Immuno Globulins (PDF)
- Nutritional Supplement Infant Formula (PDF)
- Opioid Analgesics (PDF)
- Pediatric Enteral Nutritional Supplement (PDF)
- Proprotein Convertase Subtilisin/Kexin Type 9 (PCSK9) Inhibitor (PDF)
- Testosterone Hormone Replacement (PDF)
- Therapeutic Agents in Rheumatic And Inflammatory Diseases (PDF)
- Viscosupplementation Products (PDF)
- Adult Vaccine Policy (PDF)
- Automatic Blood Pressure Monitor (PDF)
- Brand Name Drug Request (PDF)
- Drug Trial and Failure (PDF)
- Hepatitis Center of Excellence (PDF)
- High Daily Morphine Milligram Equivalent (PDF)
- IEHP Drug Prior Authorization Policy (PDF)
- Intrauterine and Subdermal Contraceptive Devices (PDF)
- Non-Formulary Drug (PDF)
- Non-Sterile Compounded Medication (PDF)
- Off-Label Indication Policy (PDF)
- Pharmacy Drug Management Program for Pain (PDF)
- Quantity Limit Policy (PDF)
- Transgender Hormonal Treatment for Adults (PDF)
- Transgender Hormonal Treatment for Pediatrics (PDF)