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Policies and Guidelines

Prior Authorization for Pharmacy Benefit Drugs

Applies for Prior Authorization Requests and Formulary Exceptions

Medica requires prior authorization for certain drugs administered under a Medica member's pharmacy benefit. This program is administered by Express Scripts®. When a prior authorization is needed for a prescription, the member will be asked to have the physician, or authorized agent of the physician, contact Express Scripts's Prior Authorization Department to answer criteria questions to determine coverage.

Prior authorization and formulary exception requests may be submitted for review. Included below is the information you need to submit a request on behalf of your patient with Medica prescription coverage.

Express Scripts offers ePA options. Click here to get started

General Express Scripts Request Form (PDF)

If you are a Minnesota physician, please submit your patient's prior authorization request using the Minnesota uniform form for prescription drug prior authorizations (PA) requests and formulary exceptions.

Prior Authorization Requests

Utilization Management Drug Policies

Commercial Large Group and Commercial Small Group Non-Specialty Prior Authorization Inquiries
Phone: 1-800-753-2851
Fax: 1-877-251-5896

Utilization Management Drug Policies

IFB and Nebraska Farm Buruea Non-Specialty Prior Authorization Inquiries
Phone: 1-800-753-2851
Fax: 1-877-251-5896

Medicare Part D Resources

Combined Medicare and Minnesota Health Care Programs Non-Specialty Prior Authorization Inquiries 
Phone: 1-800-935-6103
Fax: 1-877-251-5896

Medicare Part D Resources

Medicare Non-Specialty Prior Authorization Inquiries
Phone: 1-800-935-6103
Fax: 1-877-251-5896

Medicare Part D Resources

Medicare Non-Specialty Prior Authorization Inquiries 
Phone: 1-800-935-6103
Fax: 1-877-251-5896

Utilization Management Drug Policies

Minnesota Health Care Programs Non-Specialty Prior Authorization Inquiries
Phone: 1-800-753-2851
Fax: 1-877-251-5896

Date: 3/3/2021 2:03:08 PM Version: 4.0.30319.42000 Machine Name: PWIM4-CDWEB01