Pharmacy Prior Authorizations, Quantity Limits, Specialty Medications and Step Therapy
for HealthChoice High, High Alternative, Basic and Basic Alternative Plans and High Deductible Health Plan (HDHP)
Pharmacy Prior Authorization
Pharmacy prior authorization (PA) is a medical review that is required for coverage of certain medications such as those that:
- Are very high cost
- Have specific prescribing guidelines
- Are generally used for cosmetic purposes
- Have quantity limitations
Follow the steps below to request a prior authorization:
- Have your physician’s office call the pharmacy benefit manager toll-free at 1-800-294-5979.
- The pharmacy benefit manager will assist your physician’s office with completing a prior authorization form.
- If your prior authorization is approved, your physician’s office is notified of the approval within 24 to 48 hours. You are also notified in writing.
- If your prior authorization is denied, your physician’s office is notified of the denial within 24 to 48 hours. You are also notified in writing.
Types of Prior Authorizations
Traditional Prior Authorization (PA) Medications
Traditional prior authorization reviews typically require that specific medical criteria be met before access to the medication is allowed.
Step Therapy (ST) Medications
Step Therapy prior authorizations require you to first try a designated Preferred drug to treat your medical condition before the Plan covers another drug for that same condition. Some step therapy medications may also be limited in quantity.
Brand-Name Exception and Non-Preferred Medication Review
A prior authorization for a brand-name or non-Preferred drug may be approved when you are unable to tolerate the generic or Preferred drug.
All of these reviews follow the same process as described in the “Pharmacy Prior Authorization” section above.
Medications Limited in Quantity (QL)
Certain medications are limited in the quantity you can receive per copay based on their recommended duration of therapy and/or routine use.
If generics are available or become available for brand-name drugs that are limited in quantity, the generics are also limited in quantity. When new medications become available in drug categories that have quantity limits, they will automatically have quantity limits per copay. New drug categories also can become subject to quantity limits throughout the year.
Specialty Medications (SM)
Specialty medications are covered only if ordered through the CVS/caremark specialty pharmacy. Specialty medications are usually high-cost medications that require special handling and extensive monitoring. You must pay a copay for each 30-day fill of a specialty medication. Copays are $100 for Preferred medications and $200 for non-Preferred medications.
CVS/caremark specialty pharmacy also provides:
- Free supplies, such as needles and syringes
- Free shipping
- Refill reminder calls
- A personal counseling team of registered nurses and pharmacists
Be aware that if you don’t order your specialty medications through the CVS/caremark specialty pharmacy, you will be responsible for the full cost of your medications.
For more information, contact the CVS/caremark specialty pharmacy toll-free at 1-800-237-2767. TDD users call call toll-free 711.
Linked below are lists of medications that are excluded or subject to prior authorization and/or quantity limits. The lists are not all-inclusive and are subject to change.
HealthChoice Advanced Control Specialty Formulary
HealthChoice Drug Removals for Clients with Advanced Control Specialty Formulary