Prior authorization is required for certain drugs because they may have limited conditions for which they are prescribed, special monitoring or dispensing requirements, or an extremely high cost. Guidelines for approving coverage for prior authorization drugs are developed and approved by a panel of practicing physicians and pharmacists. The drugs covered under the medical benefit are typically administered in an office, home, or outpatient setting.
Use our online tool to search for drugs covered under the medical benefit that require prior authorization.
You can also download a PDF version of the Medical Prior Authorization List which lists those drugs requiring prior authorization that are covered under the medical benefit, as well the prior authorization request form.
Prior Authorization List for Drugs Covered Under the Medical Benefit - Commercial
Prior Authorization List for Drugs Covered Under the Medical Benefit - Medicare
Prior Authorization Request Form for Drugs Covered Under the Medical Benefit
Unless otherwise stated, please call the Authorization Unit at 330.996.8710 to initiate the prior authorization process for these items.
If you have not met with your assigned Provider Engagement Specialist or would like to schedule an in-office training or meeting to address any questions regarding the authorization process, claims issues, appeals, SummaCare products/benefits or Plan Central training, please contact the assigned Provider Engagement Specialist for your office.
View patient eligibility, benefits, claims status, and self-funded prior authorization lists, as well as review clinical edits and clarifications.