Pharmacy Services

PHP Pharmacy Services Our goal is to optimize patient outcomes through the use of medications that have established efficacy and safety data while also providing the greatest value. Certain drugs on the formulary require prior authorization, and will not be approved for payment until the conditions for approval of the drug are met and the authorization has been entered into the system. Below is a list of medications that require prior authorization. Click on the policy to open the criteria required for approval.

Updates:
Please click on the flyer below regarding October 1, 2018 changes to the formulary Please click on the flyers below regarding January 1, 2019 changes to the formulary The prescription drug formulary can be found here:

Prescription Drug Formularies

Medications administered or billed through the medical side (requires HCPCS code) can be found here:

Medication Notification Table

The medication prior authorization form can be found here:

Medication Prior Authorization Form

Medications with Drug-Specific Criteria for Prior Authorization

Criteria Medications include:
Acthar Acthar
Third-generation Anticonvulsants Vimpat, Potiga, Fycompa, Aptiom, Sabril, Briviact, Gabitril
Afinitor Afinitor
Specialty Asthma medications Xolair, Nucala, Cinqair, Fasenra
Atopic Dermatitis medications Eucrisa, Dupixent
Benlysta Benlysta
Botulinum toxin Botox
Benign Prostatic Hyperplasia Cialis for daily use
CAR-T Kymriah, Yescarta
CNS Stimulants Provigil, Nuvigil
Entyvio Entyvio
Erythropoietin Stimulating Agents Procrit, Epogen, Aranesp, Mircera
Gastrointestinal agents Xifaxan, Viberzi
G-CSF agents Neupogen, Zarxio, Neulasta, Granix
Growth Hormones Humatrope, Norditropin, Nutropin, Genotropin
Hepatitis C: Direct Acting Antivirals Sovaldi, Harvoni, Viekira Pak, Daklinza, Technivie, Zepatier
Hereditary Angioedema Agents Cinryze, Berinert, Kalbitor, Firazyr
Interleukin Inhibitors Stelara, Cosentyx
Immune globulin Hizentra, Gammagard, Privigen
Opioid antagonists for use in constipation Relistor, Movantik, Symporic
Multiple Sclerosis agents Ampyra, Gilenya, Aubagio, Tecfidera, Ocrevus
Orencia Orencia
Injectable osteoporosis agents Reclast, Prolia, Forteo
Otezla Otezla
PAH Agents Flolan, Remodulin, Tyvaso, Ventavis, Letairis, Revatio, Tracleer, Opsumit
PCSK9 Agents Praluent, Repatha
Pulmonary fibrosis agents Ofev, Esbriet
Rituxan Rituxan
Synagis Synagis
Soliris Soliris
TNF inhibitors Enbrel, Humira, Inflectra, Remicade, Cimzia, Simponi
Uridine triacetate Vistogard, Xuriden
Weight loss medications Belviq
Xiaflex Xiaflex

General Policies

Policy Description:
Dose RoundingPolicy for dosage rounding
Opioid Step Therapy and Morphine Milligram Equivalent (MME) Policy for Opioid and MME guidelines
Policy on use of formulary alternatives Based upon benefit design, a list of these medications may be found in the prescription drug list, in the HCPCS notification table for provider-administered medications, or by calling PHP customer service.
General Policy on approval duration of specialty and/or high-cost medications Subject to benefit design.



Please note: Medications requiring prior authorization, as well as criteria for use, are subject to change. For the most up-to-date information on coverage and cost of a medication, you may call the PHP Customer Service Department at 1.800.832.9186. Coverage is based on the member's benefit plan.

This page last updated November 9, 2018.