Prior Authorization Process for Non-Preferred Medications
Prior authorization is required when a provider deems it necessary and appropriate to utilize a medication that is not contained in the Select Medication List. The prior authorization process is used to establish that a particular case meets clinically driven, medically relevant criteria before the medication is approved for coverage at the preferred rate.
The following process will be required for providers requesting prior authorization for a non-preferred medication at the Preferred rate:
- The provider’s office should contact the pharmacy benefits administrator. Please have the Member ID number, medication name, and fax number ready to give to the pharmacy benefits administrator representative.
- The pharmacy benefits administrator will fax a prior authorization form to the provider’s office. This form should be completed at the provider’s office. Call the pharmacy benefits administrator to obtain the appropriate fax number.
- The provider’s office will receive a fax from the pharmacy benefits administrator which will supply notification of the review results.
- If the medication is approved for coverage under the preferred rate, the approval is loaded into the pharmacy benefits administrator’s system within 24 to 48 hours. Written notification of the approval is faxed to the provider’s office and sent to the member within 24 to 48 hours. If a non-Preferred medication is not approved through the prior authorization process, written notification is also faxed to the provider and sent to the member within 24 to 48 hours.
For additional information about the HealthChoice pharmacy benefits, reference the HealthChoice Health Plan Handbook or the Pharmacy Benefits Information on this website.