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IEHP - Inland Empire Health Plan, A Public Entity


Prior Authorization Drug Treatment Criteria

To  provide access to quality and clinically effective medications, IEHP uses a drug formulary. The IEHP Formulary provides information regarding medications covered under the benefit plans. 

Please note that coverage is not limited only to drugs  on the IEHP Formulary.  Many drugs not listed on the  Formulary  are covered through the Prior Authorization Process.

Blue Bullet Graghic  Prior authorization encourages the appropriate and rational use of medications by allowing coverage only when certain conditions are met.

Blue Bullet Graphic  The prior authorization program is based upon current medical findings, FDA-approved manufacturer labeling information, and recommendation by the IEHP Pharmacy and Therapeutics Subcommittee.

Blue Bullet Graphic  If the medication you prescibe  is not on IEHP Formulary, you or the pharmacist may request authorization for the medication by submitting a Pharmacy Exception Request (PER)  to IEHP. If the request is approved, you will be notified and the medication will  be covered. If the request is denied, you and your patient will be notified of the decision.

Any medication not on the IEHP Formulary requires prior authorization to be covered by IEHP.

The medications requiring prior authorization are subject to change.

Please select a drug from the list below to view the treatment criteria/guideline:

 

AccuChekRegistered Trade Mark (monitor & test strips)
AciphexRegistered Trade Mark (rabeprazole)
AdipexRegistered Trade Mark (phentermine)
AllegraRegistered Trade Mark (fexofenadine)
AmbienRegistered Trade Mark (zolpidem)
AvonexRegistered Trade Mark (interferon beta-1A)
AzilectRegistered Trade Mark (rasagiline)
BetaseronRegistered Trade Mark (interferon beta-1B)
ByettaRegistered Trade Mark (exenatide)
CesametRegistered Trade Mark (nabilone)
ChantixRegistered Trade Mark (varenicline)
ClarinexRegistered Trade Mark (desloratadine)
CymbaltaRegistered Trade Mark (duloxetine)
DacogenRegistered Trade Mark (decitabine)
DaytranaRegistered Trade Mark (methylphenidate transdermal)
DarvocetRegistered Trade Mark N-100 (acetaminophen/propoxyphene)
ElestatRegistered Trade Mark (epinastine)
ElidelRegistered Trade Mark (pimecrolimus)
EmpirinRegistered Trade Mark w/Codeine (aspirin/codeine)
EmsamRegistered Trade Mark (selegiline)
EnbrelRegistered Trade Mark (etanercept)
EraxisRegistered Trade Mark (anidulafungin)
ExuberaRegistered Trade Mark (insulin)
FlolanRegistered Trade Mark (epoprostenol)
GenotropinRegistered Trade Mark (somatropin)
HumatropeRegistered Trade Mark (somatropin)
HumiraRegistered Trade Mark (adalimumab)
HyalganRegistered Trade Mark (Sodium hyaluronate)
KineretRegistered Trade Mark (anakinra)
LamisilRegistered Trade Mark (terbinafine)
LexaproRegistered Trade Mark (escitalopram)
LorcetRegistered Trade Mark (acetaminophen/hydrocodone)
LucentisRegistered Trade Mark (ranibizumab)
LupronRegistered Trade Mark (leuprolide)
LyricaRegistered Trade Mark (pregabalin)
MeridiaRegistered Trade Mark (sibutramine)
MS ContinRegistered Trade Mark (morphine sulfate)
MyozymeRegistered Trade Mark (alglucosidase alfa)
NicodermRegistered Trade Mark (nicotine)
NicoretteRegistered Trade Mark (nicotine)
NicotrolRegistered Trade Mark (nicotine)
NorcoRegistered Trade Mark (acetaminophen/hydrocodone)
NorditropinRegistered Trade Mark (somatropin)
Nutritional Supplement - Infant & Adult
NutropinRegistered Trade Mark (somatropin)
OrenciaRegistered Trade Mark (abatacept)
OrthoviscRegistered Trade Mark (Sodium hyaluronate)
OxyContinRegistered Trade Mark (morphine sulfate)
PrevacidRegistered Trade Mark (lansoprazole)
ProtonixRegistered Trade Mark (pantoprazole)
RanexaRegistered Trade Mark (ranolazine)
RebifRegistered Trade Mark (interferon beta-1A)
RemicadeRegistered Trade Mark (infliximab)
RemodulinRegistered Trade Mark (treprostinil)
RituxanRegistered Trade Mark (rituximab)
RozeremRegistered Trade Mark (ramelteon)
SingulairRegistered Trade Mark (montelukast)
SonataRegistered Trade Mark (zaleplon)
SpirivaRegistered Trade Mark (tiotropium)
SporanoxRegistered Trade Mark (itraconazole)
StratteraRegistered Trade Mark (atomaxetine)
SupartzRegistered Trade Mark (Sodium hyaluronate)
SymlinRegistered Trade Mark (pramlintide)
SynagisRegistered Trade Mark (palivizumab)
SynviscRegistered Trade Mark (hylan G-F20)
TracleerRegistered Trade Mark (bosentan)
TrileptalRegistered Trade Mark (oxcarbazepine)
TylenolRegistered Trade Mark w/Codeine (acetaminophen/codeine)
VentavisRegistered Trade Mark (iloprost)
ViagraRegistered Trade Mark (sildenafil)
VicodinRegistered Trade Mark (acetaminophen/hydrocodone)
Wellbutrin XL Registered Trade Mark (bupropion)
XenicalRegistered Trade Mark (orlistat)
XolairRegistered Trade Mark (omalizumab)
XopenexRegistered Trade Mark (levalbuterol)
ZofranRegistered Trade Mark (ondansetron)
ZoloftRegistered Trade Mark (sertraline)
ZybanRegistered Trade Mark (bupropion)
ZyrtecRegistered Trade Mark (cetirizine)