Medical management

• Medical prior authorization service list

• Non-covered services

• Medical policies
• Drug policies
• Medical oncology drugs (effective 1/1/23)
• Medical non-oncology drugs (effective 10/1/2023)
• Clinical guidelines

Medical injectables

Medical benefit prior authorization form

Medical oncology drugs (effective 1/1/23)

Medical non-oncology drugs (effective 10/1/2023)

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Exception to coverage forms

For new FDA-approved drugs on the market for less than a year that haven't been reviewed or granted approval through the Pharmacy & Therapeutics Committee

• Pharmacy drug
• Medical injectable drug