Coverage Determination Request
The coverage determination process ensures that medication regimens that are high risk, have a high potential for misuse, or have narrow therapeutic indices are used appropriately and according to FDA-approved indications.
- Electronic Prior Authorization (ePA): Cover My Meds
- Online: Complete a Request for Medicaid Prescription Drug Coverage Determination
- Fax: Complete a Coverage Determination Request (PDF)
Providers may request an addition or exception for the following:
- Drugs not listed in the formulary
- Duplication of therapy
- Prescriptions that exceed the FDA daily or monthly quantity limit
- Most self-injectable and infusion medications
- Drugs that have an age limit
- Drugs included on the Preferred Drug List (PDL) that require prior authorization (PA)
- Brand name drugs when a generic exists
- Drugs that have a step therapy (ST) and the first-line therapy is inappropriate