Prior Authorization for Medication Process
Prior authorization is required for certain medications to be covered by HealthChoice and to request a tier exception for a member. 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 appropriate tier.
Providers who request prior authorization must follow the following process:
- The provider’s office must contact the pharmacy benefit manager (PBM). Please have the member ID number, medication name and fax number ready to give to the PBM representative.
- The PBM will do one of two things:
- Fax a prior authorization form to the provider’s office. This form must be completed at the provider’s office.
- In some scenarios the required information can be taken verbally over the phone. In this instance the PBM representative will ask the necessary questions and record the answers given.
- Once the PBM completes their review, the member and the provider’s office are sent notification of the review results.
- If the medication is approved for coverage, the approval is loaded into the PBM’s system within 24 to 48 hours. Written notification of the approval is sent to the provider’s office and sent to the member within 24 to 48 hours. If the medication is not approved through the prior authorization process, written notification is faxed to the provider and sent to the member within 24 to 48 hours, along with information for appealing the denial.
For additional information about the HealthChoice pharmacy benefit, reference The HealthChoice High, High Alternative, Basic, and Basic Alternative Plans Handbook at www.ok.gov/sib/documents/HealthHandbook.pdf or this website at www.ok.gov/sib/Member/Pharmacy_Benefits_Information/index.html.