Common use of Prior Authorization Program Clause in Contracts

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.