Understanding Prior Authorization

Why have I received this information?

This information has been prepared for you by Anthem Prescription Management, your pharmacy benefit manager. From time to time, your physician may prescribe a medication that requires prior authorization. As a result, we think you will find a general understanding of this process helpful.

What is prior authorization?

Prior authorization is the process of obtaining approval for benefits before they may be approved to pay for certain prescriptions or refills. The prior authorization process is normally used to monitor the prescribing of certain drugs, to help promote utilization of prescription benefits that are safe and cost-effective.

When your physician has prescribed a medication for you that requires a prior authorization, your pharmacist will receive an electronic message sent to their computer at the point-of-sale.

DID YOU KNOW? Many other insurance companies require that your doctor call before a prior authorization may be approved. Your health plan gives your pharmacist the freedom to call the health plan directly regarding benefit approvals for certain medications. This process may save you and your pharmacist valuable time.

Which medications require prior authorization?

Androderm® Intron A® Remicade®
AndroGel® Iressa® Revatio®
Android® Kineret® Roferon-A®
Delatestryl® Lyrica® Striant®
Depo-Testosterone® Malarone® Testim®
Enbrel® Mepron® Testopel®
Forteo™ Methitest Testred®
Gleevec® Panretin® Gel Testosterone Cream®/Ointment
Growth Hormone Pegasys® Thalomid®
Halotestin® Peg-Intron Topamax®
Humira® Provigil®  
Infergen™ Rebetron™  

Other drugs may require prior authorization, according to your health benefit coverage. Examples may include ADHD medications, oral contraceptives, growth hormones or certain acne medications.

What should I do first?

Ask your pharmacist to call Anthem Prescription at 1 (800) 662-0210. Customer service representatives are available to assist Monday - Friday, 8:30 a.m. to Midnight, Eastern time, Saturday, 9 a.m. to 7 p.m., Eastern time and Sunday, 9 a.m. to 5 p.m., Eastern time. Your pharmacist will need to provide the following information:

APPROVED: If the health plan benefit criteria are met, an authorization will be entered to allow your claim to process immediately.

MORE INFO NEEDED:If more information is needed, a representative may contact your physician. Once the relevant information is received from your doctor, and if the benefit approval criteria are met, the Prior Authorization will be approved.

If the review does not satisfy the approval criteria approved by your health plan, the claim will be sent to your health plan for review. If the health plan concludes the benefit should be denied, it will issue denial letters to both you and your doctor that clearly outline the appeals and/or grievance process.

Please Note: Due to varying health benefit plans, inclusion of a drug and related items on the drug list/formulary is not a guarantee of coverage. Please refer to your prescription drug benefit description of coverage, limitations and exclusions.