What if my drug requires a prior authorization review?

Some medications will require a pharmacist review prior to the plan paying for the medication.  These medications include, but are not limited to, high cost medications, specialty medications, and medications that have a high potential for abuse or addiction.

If one of your medications requires an authorization and the pharmacy attempts to fill the medication, a rejection message will be sent to the pharmacy to let them know that the medication requires a review prior to approval.  We will then reach out to your prescribing physician to request specific information regarding the medication.  Our clinical staff will then review the medication and determine if it meets the criteria for approval.  If the medication is approved we will reach out to the pharmacy and allow them to process the claim.

If the medication is denied upon review we will send you and the prescribing physician a letter detailing the reason for the denial and outlining any steps you may be able to take to appeal the denial.

If you have any questions about the status of a prior authorization please contact our help desk at 877.643.2067