Prior Authorization Guidance
Helpful tips and steps to take when a prescribed medication requires Prior Authorization for coverage under your plan
Why do some drugs require prior authorization for coverage under the plan?
Drugs requiring prior authorization by your health plan, go through a review process to evaluate whether or not the medication is reimbursable under the plan. As part of the review process, the prescribing clinician is contacted to obtain medical history and other records needed to complete the review.
Please note, the prior authorization process follows steps required under your health plan and is applied equally and consistently for all individuals enrolled in the plan. US-Rx Care representatives are happy to help you understand and navigate the process but are not able to alter the process or by-pass plan coverage criteria for individual cases.
Here are steps you can take depending on a requested drug’s status in the prior authorization process.
Your doctor has been contacted by US-Rx Care to obtain needed information to conduct a prior authorization review.
Steps To Take
- Call your doctor’s office to make sure they provide US-Rx Care will ALL requested documents.
- The most common reason for delay is no or an incomplete response from the prescribing clinician.
- A prior authorization form is available at US-Rx/Providers for doctors to complete and send to US-Rx Care along with needed medical records.
A request for prior authorization has been denied for lack of information received from the prescriber.
Steps To Take
The most common reason for delay is no or an incomplete response from the prescribing clinician.
Call your doctor’s office to make sure they provide US-Rx Care will ALL requested documents. If they believe they have provided all necessary documents, ask them to call the US-Rx Care prescriber assistance line at 877-249-8892 to confirm what missing information is preventing completion of the prior authorization review.
A request for prior authorization has been approved.
Steps To Take
Call your doctor’s office for any special instructions. If the medication can only be obtained from a specialty pharmacy, your doctor has been provided the name and contact information for the pharmacy. Specialty medications typically require special handling and thus are dispensed by pharmacies specialized in dispensing these types of medications. For all other medications, you can use any local retail pharmacy or the plan’s mail order pharmacy. It is always recommended that your first 1 or 2 fills come from a local pharmacy (to make sure everything is as expected with the medication), before going to mail for 90-day supplies.
The dispensing pharmacy will need a prescription from your doctor (which they can receive electronically or by fax or by phone). Confirm with you doctor where the medication will be dispensed and ensure your doctor sends a prescription there for you to fill.
An alternative for a drug requested by your doctor has been approved.
Steps To Take
Through the prior authorization review process, an alternative medication may be approved instead of the medication originally requested by your doctor. There can be multiple common reasons when this happens, including one or more of the following:
- The requested medication is not covered through the plan (non-formulary / non-covered item)
- The alternative medication is required “first line” therapy, prior to adding or taking a requested “second line” therapy.
- The requested medication is not FDA approved for the prescribed use or is not recognized standard of care
Approved alternatives are always well established, safe and effective therapies for the condition being treated. Simply ask your doctor to send a prescription for the dispensing pharmacy so you can start your medication immediately.
If you or your doctor disagrees with the outcome of a prior authorization review, an appeal can be filed. The appeal process can be found in your plan benefits document, or you can contact US-Rx Care at 877-249-8892 for appeal instructions as well. Your doctor may wish you to start taking the approved therapy, during the appeal process, so you don’t go without any medication for your condition. You may discover that the approved therapy works just fine for you.
A drug requested by your doctor is not covered under the plan, and no alternative is approvable under the plan.
Steps To Take
The most common reason for coverage denial is a condition being treated that is not eligible for medication coverage through the plan. For example, a drug used for cosmetic purpose such as wrinkles. In such cases, no alternative medication would be covered, again because of the condition being treated. Another common reason is lack of medical necessity for or incorrect diagnosis of the condition to be treated. For example, use of testosterone or growth hormone when required blood testing shows normal levels for the hormone(s).
If you or your doctor disagrees with the outcome of a prior authorization review, an appeal can be filed. The appeal process can be found in your plan benefits document, or you can contact US-Rx Care at 877-249-8892 for appeal instructions as well.
If none of the above scenarios fit your case, please call US-Rx Care at 877-249-8892 so a representative can assist to navigate your specific case. Please note, the prior authorization process follows your plan’s requirements, and is applied equally and uniformly for all individuals enrolled in the plan.