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


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:

Medi-Cal PA Drug Criteria Summary Table - Click Here

To view Drug Criteria Referenced in Summary Table - Click Links Below:

Clinical Practice Guidelines - CPGs

Drug Prior Authorization Criteria