Prior Authorization

Certain covered drugs that have been approved by the U.S. Food and Drug Administration (FDA) for specific medical conditions require prior authorization. The approval criteria are developed and endorsed by our Pharmacy and Therapeutics Committee and are based on information from the FDA, manufacturer guidelines, medical literature, actively practicing consultant physicians, and appropriate external organizations.

Please see the bottom of the page for other types of requests such as:

A request form must be completed for all medications requiring prior authorization. Our pharmacy benefit manager, FutureScripts® Secure, reviews all requests. Please visit their site in order to obtain the appropriate prior authorization form.

Please find the drug in the appropriate formulary to determine if prior authorization is required.

How to Submit a Prior Authorization Request

Providers:

  1. When filling out a prior authorization form, all requested information must be supplied. Incomplete requests will be faxed back to your office for completion, which will delay the decision process.
  2. Fax completed forms to FutureScripts® Secure for review at 1-888-671-5285. Make sure you include your office telephone and fax numbers on the form.
  3. You will be notified by fax if the request is approved or denied. You and your patient will also receive a denial letter if the request is denied.
  4. If you have not received a response 72 hours after submitting complete information, contact FutureScripts Secure at 1-888-678-7015, Option 1.

Members:

  1. Take the appropriate request form to your physician to be completed.
  2. You or your physician may fax the completed form to FutureScripts Secure for review at
    1-888-671-5285.
  3. If you have not received a response from your provider after 72 hours, contact the provider who requested the prior approval on your behalf.
  4. If you have questions, please contact Customer Service.

Tiered cost-sharing and Formulary exceptions

Tier Cost Sharing

The plan puts each covered drug into one of several different cost-sharing tiers. How much you pay for your prescription depends in part on which cost-sharing tier your drug is in. For drugs in the non-preferred brand tier, you and your provider can ask the plan to make an exception to allow at the preferred brand tier drug so that you pay less for it. If your provider says that you have medical reasons that justify asking us for an exception, your provider can help you request an exception to the non-preferred tier. See instructions below for requesting an exception.

If the non-preferred request is approved, the drug will be processed at the appropriate preferred formulary benefit cost-sharing. If the request for access at the preferred tier is denied, you and your physician will receive a denial letter that explains the appeal process. You may still receive benefits for the drug at the non-preferred cost-sharing.

Please note that certain drugs in some of our cost-sharing tiers are not eligible for this type of exception. We do not lower the cost-sharing amount for drugs for the following:

  • Specialty tier
  • Non-preferred generic
  • Cost-share based on coverage phases, such as the coverage gap.

Formulary Exception

If your drug is not on the plan’s List of Covered Drugs (Formulary) or is restricted, you can request an exception and ask the plan to cover the drug. You and your provider can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If your provider says that you have medical reasons that justify asking us for an exception, your provider can help you request an exception to the rule.

Requesting a Tier Cost–Sharing or Formulary Exception

You, your doctor, or someone you've authorized may make an oral or written, standard or expedited Exception request:

  • Call 1-888-678-7015.
  • TTY/TTD 1-888-857-4816.
  • Fax 1-888-671-5285.
  • Write FutureScripts Secure
    P.O. Box 37694
    Philadelphia, PA 19103-0694

If you submit the request, a supporting statement is needed from your physician in order to complete the review. The physician may provide the supporting statement by calling the number above or by completing the PDF icon Coverage Determination Form providing details to support use of the non-preferred/formulary medication and faxing the request to 1-888-671-5285. The Coverage Determination Form can also be obtained by calling 1-888-678-7015, Option 3.

It is important to be sure to select the appropriate option indicating the “Type of Coverage Determination Request.”

Medicare Part B vs. Part D Determinations

CMS limits coverage of some drugs to either the Part B or Part D benefit depending on how the drug is prescribed, dispensed and/or administered. Please refer to the appropriate formulary above to determine if your drug requires a Medicare Part B vs. Part D determination. Please complete the PDF icon Medicare Administrative Prior Authorization for Part B/D coverage form if needed.

Certain drugs are generally only covered under the Part B benefit. These drugs typically will not be listed on the formulary. However, some Part B drugs require pre-certification. Please see the attachment below to determine if pre-certification is required:

PDF icon Specialty Drugs Requiring Precertification Y0041_HM_12_1094 CMS Approved 8/12/2012

Your physician may refer to the Direct Ship Injectables Program for more information about certain injectable drugs covered under Medicare Part B benefit.

Redetermination

Upon denial, the member and the provider will receive a letter describing the decision, appeal rights and contact information. If you and/or your physician disagree with the decision, you need to call or write to your plan to ask for a formal redetermination. Please complete the appropriate form below:

For more information about redeterminations, visit our Organization Determination, Appeals, and Grievances page.

Website last updated: 5/16/2013
Y0041_HM_13_3639d Pending

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