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Prior authorizations and exception to coverage - Covered CA and IFP

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A prescriber must fill out a Standard California Prescription Drug Prior Authorization form for a member to get a drug that is not on the formulary. The form will be reviewed by a pharmacist and/or a physician and approval will be based on established medical criteria and/or medical necessity. A list of formulary drugs and medical criteria are available at www.valleyhealthplan.org or by calling VHP Member Services at 1.888.421.8444 (toll-free). 

The prescriber must completely fill out the Standard California PA form with information that supports the request for a drug not on formulary and submit to the PBM. The form will be reviewed and approved based on established medical criteria and/or medical necessity and the member and provider will receive communication with the decision.

  • The Standard California PA form request will be turned around within 72 hours for nonurgent requests, and within 24 hours if exigent circumstances exist, upon receipt of a completed prior authorization request from a prescribing provider.

  • Exigent circumstances” exist when an enrollee is suffering from a health condition that may seriously jeopardize the enrollee’s life, health, or ability to regain maximum function or when an enrollee is undergoing a current course of treatment using a nonformulary drug.

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