Prior Authorizations

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Quality drug therapy with the Prior Authorization Program

Using medications correctly helps prescription drugs have the best chance of being effective for treating a condition. Our Prior Authorization program aims to improve the quality of drug therapy by:

  • Guiding the appropriate use of medications
  • Confirming the appropriate length of drug therapy

How the program works

When a member fills a prescription, we review it to see if it meets recommended guidelines.

  • If it meets the guidelines, the prescription will be filled without interruption.
  • If it doesn’t meet the guidelines, the prescription will go through a review and approval process before being filled. This could take additional time and we will contact the member to explain why we need to review the prescription further and to see if they have enough medication on hand to last through this review process.

Review process

The prior authorization process is simple. A doctor or pharmacist can complete either our Prior Authorization Form (PDF), submit the form online use the Oregon Prior Authorization (PDF) form, or call 800-643-5918, or fax 888-437-1510.

Once we receive the form, we will follow the Medication Policy Criteria for the specific drug and make a decision based on the information submitted and the medication policy criteria. Medication policy criteria have been developed based on scientific evidence, with the input from providers and pharmacists right here in our community to guide members to take the right medications at the right time

The review process takes one to two business days. If the prescription is approved, then it’s covered and can be filled the same day. If it’s not approved, we will contact the member to explain this and discuss their options.

Providers

For Medicare Part D Beneficiaries who are Hospice Patients who are taking the following categories of medications: analgesics, antinauseants (antiemetics), laxatives, and antianxiety drugs (anxiolytics), and it is unrelated to their Hospice status, please use the below form to allow for the medication to pay under the member’s Part D benefit.

Hospice Coverage Determination

For all other Coverage Determination requests for Medicare Part D please use the following form:

Prescription Coverage Determination

 

Medications subject to the Prior Authorization Program

If prior authorization is required for a drug, it will be marked with PA in the formulary. For an updated list of medications that require prior authorization, click on the link for your plan:

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