Prior Authorization Program Clause Samples

The Prior Authorization Program clause establishes a requirement for certain services or procedures to receive approval from a designated authority, such as an insurer or plan administrator, before those services are provided. In practice, this means that healthcare providers or patients must submit requests for specific treatments, medications, or procedures and await confirmation that these are covered under the relevant plan. This process helps control costs and ensures that only medically necessary and covered services are utilized, thereby preventing unnecessary expenditures and promoting efficient use of resources.
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 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.
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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.
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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. 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 ▇▇▇▇▇▇▇.▇▇▇, under “View Medical Benefit Details” Inpatient Prior Authorization reviews both the necessity for the admission and the need for continued stay in the hospital.  call Cigna at the number on the back of your ID card, or  check ▇▇▇▇▇▇▇.▇▇▇, under “View Medical Benefit Details”
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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.
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Prior Authorization Program. The prior authorization (PA) program applies to a limited number of drugs and, as its name suggests, prior approval is required for coverage under the program. If the insured person submits a claim for a drug included in the PA program and has not been pre-approved, the claim will be declined. In order for drugs in the PA program to be covered, the insured person needs to provide medical information using Sun Life's PA form. Both the insured person and the attending physician need to complete parts of the form. The insured person will be eligible for coverage for these drugs if the information provided by the insured person and the attending physician meets Sun Life’s clinical criteria based on factors such as: • Health Canada Product Monograph. • recognized clinical guidelines. • comparative analysis of the drug cost and its clinical effectiveness. • recommendations by health technology assessment organizations and provinces. • the insured person’s response to preferred drug therapy. If not, the claim will be declined. The prior authorization forms are available from the following sources:
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Related to Prior Authorization Program

  • Prior Authorization A determination to authorize a Provider’s request, pursuant to services covered in the MississippiCAN Program, to provide a service or course of treatment of a specific duration and scope to a Member prior to the initiation or continuation of the service.

  • Power; Authorization Such Investor has all requisite power and authority to execute and deliver this Agreement. This Agreement, when executed and delivered by such Investor, will constitute a valid and legally binding obligation of such Investor, enforceable in accordance with its respective terms, except as: (a) limited by applicable bankruptcy, insolvency, reorganization, moratorium and other laws of general application affecting enforcement of creditors’ rights generally; and (b) limited by laws relating to the availability of specific performance, injunctive relief or other equitable remedies.

  • Authorization, Etc This Agreement and the Notes have been duly authorized by all necessary corporate action on the part of the Company, and this Agreement constitutes, and upon execution and delivery thereof each Note will constitute, a legal, valid and binding obligation of the Company enforceable against the Company in accordance with its terms, except as such enforceability may be limited by (i) applicable bankruptcy, insolvency, reorganization, moratorium or other similar laws affecting the enforcement of creditors’ rights generally and (ii) general principles of equity (regardless of whether such enforceability is considered in a proceeding in equity or at law).

  • Cloud Computing State Risk and Authorization Management Program (TX-RAMP In accordance with Senate Bill 475, Acts 2021, 87th Leg., R.S., pursuant to Texas Government Code, Section 2054.0593, Contractor acknowledges and agrees that, if providing cloud computing services for System Agency, Contractor must comply with the requirements of the state risk and authorization management program and that System Agency may not enter or renew a contract with Contractor to purchase cloud computing services for the agency that are subject to the state risk and authorization management program unless Contractor demonstrates compliance with program requirements. If providing cloud computing services for System Agency that are subject to the state risk and authorization management program, Contractor certifies it will maintain program compliance and certification throughout the term of the Contract.

  • Authorization, Approval, etc No authorization, approval, or other action by, and no notice to or filing with, any governmental authority, regulatory body or any other Person is required either (a) for the pledge by the Pledgor of any Collateral pursuant to this Pledge Agreement or for the execution, delivery, and performance of this Pledge Agreement by the Pledgor, or (b) for the exercise by the Collateral Agent of the voting or other rights provided for in this Pledge Agreement, or, except with respect to any Pledged Shares, as may be required in connection with a disposition of such Pledged Shares by laws affecting the offering and sale of securities generally, the remedies in respect of the Collateral pursuant to this Pledge Agreement.