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Prior Authorization Program

To promote appropriate use of medications by our members, while guiding members away from unproven or experimental uses, OmedaRx has implemented prior authorization and quantity level limits for select medications.

We review all medications on our formularies to identify which drugs should be part of the prior authorization and quantity limits programs. During our review, OmedaRx pharmacists and physicians check for medications that meet at least one of the following criteria:

  • May be prone to overuse or present potential safety issues.
  • Have limited uses based on scientific studies or FDA approval.
  • May be prescribed for conditions that are not a covered benefit.
  • Require medical diagnostic tests to ensure a medical benefit.
  • Have other equivalent, but less expensive options available.

When you submit a prior authorization request, OmedaRx Clinical Pharmacists and Medical Directors will review it and respond in writing (usually by fax) within 24 to 48 (business) hours. We also include detailed information, including educational information when available, about the rationale if a request is denied.

Quick, Automated Approvals

To reduce paperwork for you and your staff, we’ve established an efficient process for automating authorizations. As part of this automation process, claims are approved instantly when certain criteria match previously approved prescription claims. This automated approval is sometimes referred to as a “step-edit”, and it eliminates the need for you (the physician) to submit information for review. By implementing this process, we’ve decreased manual approvals by 25%, eliminated costs and improved customer service.

If you would like to submit information manually to bypass this automated step-edit process, or view a current list of medications that require Prior Authorization or are subject to a quantity limitation, please see our Prior Authorization Program page for details.

Substitution Process

OmedaRx has developed Formularies to communicate which drugs are covered under our plans. We encourage the use of the medications on a patient’s specific Formulary, as we have assessed them to be the most effective and affordable options.

You can help your patients (our members) by selecting medications that are included on their formulary when medically appropriate. If a member is on a closed formulary plan and the medication you are prescribing is not on the formulary, it will not be covered under their plan. However, we do understand that there is sometimes a medical reason for prescribing a medication that is not included in our formulary. if you deem a non-formulary medication to be medically necessary, you can request an exception and we will consider covering that medication a case by case basis. This request is part of our Substitution Process.


If you have any questions, contact us. If your patients have questions about prescription benefits, they can call the number on the back of their member ID card. Members with hearing impairments may call the TTY line at 711, a free service provided by the Public Utility Commission.


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