Utilization for Non-PA Coverage Rules

provider vendors are strongly encouraged to initiate an epa if the target medication has an indication that prior authorization may be required additionally, coverage factors can help to determine when an epa may be required example coverage limit example gender limit the gender limit indicates coverage for females only, but the doctor wants to prescribe for a male patient age limit the age limit indicates a cap at 30 years of age, but the doctor wants to prescribe for a 43 year old patient quantity limit the quantity limit coverage list indicates a coverage limit of 15 days for imitrex, a migraine treatment, but the doctor wants to prescribe a 30 day treatment step medication the step medication list indicates that before bextra (a cox 2 inhibitor) is covered, at least one medication from the cox 1 inhibitor category must be tried (e g ibuprofen), but the doctor wants to prescribe bextra without trying a cox 1 inhibitor first step therapy the step therapy coverage list identifies medications that must be tried before the patient can receive coverage for retin a, a brand of dermatologic preparation used to treat acne, but the patient has already failed treatment with generic topical tretinoin