2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

PharmacyTypes of Pharmacy Prior Authorization Requests• Medications listed on a formulary that require priorauthorization with application of specific clinical criteria.• Request for an exception to a formulary (non-formularyrequest).• Requests for a quantity or frequency (including vacation)override.General Processing Routine Pharmacy Prior AuthorizationRequests by Fax, Mail, or Online• The provider generates a request for a medication requiringprior authorization, using the pharmacy services priorauthorization form.• All requests are submitted directly into our automated priorauthorization system or manually entered into the system bythe technician if they did not come online or through fax.• Verification of eligibility and benefits, including the verificationof the plan to which the Presbyterian Centennial Caremember belongs and the original effective date is requiredfor all requests and in online submissions. This is anautomated feature.• The Benefit Plan is evaluated to assure the request is for acovered benefit.• All pertinent medical information is gathered, includingmedical documentation.• Requests are evaluated using appropriate criteria, includingmember claim history.Revised RequestsFollowing discussion between the provider and thepharmacy benefit technicians or clinical pharmacist,the request may be changed to a mutually agreeduponalternative medication. All changes aredocumented on the original request.Processing of Approved Pharmacy PriorAuthorization RequestsWhen a request is approved, the provider is notifiedby telephone or fax. If approved, authorization formedication is automatically entered into the onlinesystem for claims processing.Processing of Pended Pharmacy PriorAuthorization RequestsIf the request is pended, the reason (such as theneed for additional medical information) is indicatedin the pharmacy prior authorization request. Ifadditional information is needed to determine ifcriteria for coverage is met, additional information isrequested by phone or fax. A phone call is madeevery 24 hours to the requesting provider to obtainupdated information. If no additional information tosupport the request is received after three businessdays, a denial is issued.Processing of Denied Pharmacy Prior AuthorizationRequestsThe denial form, a copy of the pharmacy priorauthorization request, and all pertinent medicalinformation available are presented to a medicaldirector for review and signature. All requests thatare denied based on medical necessity must bereviewed by the pharmacist and by a medicaldirector. The requesting provider shall be advisedof the denial, rationale, and alternatives available.Under no circumstance may this responsibility bedelegated to non-medical personnel. A denial letteris sent to the member within 24 hours ofdetermination. Copies are also sent to therequesting provider and stored in the Presbyterianautomated system. All denial letters includeappeals rights language to assist the member orprovider in filing an appeal if they choose to do so.Expedited Pharmacy Prior Authorization RequestsA request for an expedited pharmacy priorauthorization is prioritized by the PharmacyDepartment staff for immediate action.Determination is made within 24 hours of receipt ofemergency requests. Pharmacy Department benefittechnicians immediately evaluate and apply theappropriate criteria which, if approved, are8-122014 Practitioner and Provider Manual - Ver. 3