Prior Authorization Program. Certain Prescription Drugs and Supplies and OTC Drugs require prior authorization from us in order to be covered. If you do not obtain an authorization when one is required we will deny coverage. Prescription Drugs and Supplies and OTC Drugs that require prior authorization are marked in the Medication Guide with a special symbol. If your Provider prescribes a medication for you that requires prior authorization, ask him or her to get an authorization for you before you go to pick it up. When the prior authorization decision has been made, we will let you and your Provider know. You may call the customer service phone number on your ID Card if you would like more information on our pharmacy utilization review program. Your Pharmacist may also tell you if a Prescription Drug or OTC Drug requires prior coverage authorization. Step Therapy Step therapy is a process in which You may need to use one (1) or more types of Prescription Drug before We will cover another as Medically Necessary. We check certain Prescription Drugs to make sure that proper prescribing guidelines are followed. These guidelines help You get high quality and cost-effective Prescription Drugs. The Prescription Drugs that require Preauthorization under the step therapy program are also included on the Preauthorization drug list. If coverage is denied, You are entitled to an Appeal as outlined in the Utilization Review and Complaints, Appeals and External Review sections of this Policy.
Prior Authorization Program. Cigna provides You with a comprehensive personal health solution medical management program which focuses on improving quality outcomes and maximizes value for You. PRIOR AUTHORIZATION FOR INPATIENT SERVICES Prior Authorization is required for all non-emergency inpatient admissions, and certain other admissions, in order to be eligible for benefits. FAILURE TO OBTAIN PRIOR AUTHORIZATION PRIOR TO AN ELECTIVE ADMISSION to a Hospital or certain other facilities MAY RESULT IN A PENALTY. Prior Authorization can be obtained by You, Your Family Member(s) or the Provider by calling the number on the back of Your ID card. To verify Prior Authorization requirements for inpatient services including which other types of facility admissions require Prior Authorization, You can: call Cigna at the number on the back of your ID card, or check xxxxxxx.xxx, under “View Medical Benefit Details” Please note that emergency admissions will be reviewed post admission. Inpatient Prior Authorization reviews both the necessity for the admission and the need for continued stay in the hospital. PRIOR AUTHORIZATION OF OUTPATIENT SERVICES Prior Authorization is also required for select certain outpatient procedures and services in order to be eligible for benefits. FAILURE TO OBTAIN PRIOR AUTHORIZATION PRIOR TO CERTAIN ELECTIVE OUTPATIENT PROCEDURES AND SERVICES MAY RESULT IN A PENALTY. Prior Authorization can be obtained by You, Your Family Member(s) or the Provider by calling the number on the back of Your ID card. Outpatient Prior Authorization should only be requested for non- emergency procedures or services, at least four working days (Monday through Friday) prior to having the procedure performed or the service rendered. To verify Prior Authorization requirements for outpatient procedures and services, including which procedures and services require Prior Authorization, You Can: call Cigna at the number on the back of your ID card, or check xxxxxxx.xxx, under “View Medical Benefit Details”
Prior Authorization Program. The Contractor must provide a state of the art prior authorization (PA) program. These services must encompass drugs processed through both the pharmacy benefit and those physician- administered drugs processed through the medical benefit. The PA program must be capable of utilizing medical codes such as CPT, HCPCS, ICD-9, and ICD-10 codes to make PA determinations in an automated fashion through POS. In addition, the PA process must accommodate the electronic submission of forms, via provider portals, to the provider call center for manual PA determinations. The PA program must include a process by which providers may request a non-preferred drug on the PDL with clinical criteria for use (PA), quantity limits, step therapy, and other coverage limitations. The Contractor must develop and communicate to providers and other interested parties, all clinical criteria, procedures for its application, and proper documentation of all clinical decisions. The Contractor shall conduct all first reconsideration review of denials by a staff clinical pharmacist and/or and physician, and must provider proper written notification of all denials and approvals to members and providers within timelines established by applicable Federal and State laws and State policies. Additionally, the Contractor must provide detailed and ongoing evaluation of the PA program such as evaluation of drugs, criteria, return on investment, and recommendations for change. Provider PA support must be supported by a clinical decision rules engine and workflow support products. The PA program must be further supported by clinical, pharmacy, and technical staff to support PA consulting and design, as well as support PA determinations as part of ongoing operations.
Prior Authorization Program. Meritain shall arrange for prior authorization services through the PBM Vendor (“PA Program”), and drugs subject to the PA Program (“PA Drugs”) are determined by the PBM Vendor. Under the PA Program, prior authorization from the PBM Vendor is required for any PA Drugs prior to being covered as a Covered Drug under the PBM Plan. Client acknowledges that the PA Program is based solely on objective criteria and the limited amount of patient information made available in the process of considering a request for prior authorization, and that determining whether to authorize coverage of a PA Drug under the PA Program is based on industry standard guidelines selected by the PBM Vendor. The PBM Vendor may rely entirely upon information about the PBM Participant and the diagnosis of the PBM Participant’s condition provided to it from sources deemed reliable, including but not limited to the Prescribing Provider and the dispensing pharmacist. Notwithstanding the foregoing, none of Meritain or any of its affiliates, nor PBM Vendor, will undertake, and none of the foregoing are required, to make diagnoses, or to substitute its judgment for the professional judgment and responsibility of the Prescribing Provider.
