For some drugs that you prescribe, Premera reviews the circumstances before deciding whether to cover the drug.
This approval process can be triggered by several different situations:
- Prior authorization—The drug is on a plan's drug list, but it requires an authorization before the prescription is covered.
- Quantity limit—The drug is on a plan's drug list, but we limit the amount of the drug that we will cover.
- Step therapy—The drug is on a plan's drug list, but we require that you first try a different drug before authorizing the drug prescribed.
- Formulary exception—The drug is not on a plan's drug list, but you have prescribed it.
- Pharmacy exception—The patient is covered by a Washington state fully insured group plan, and a prescription was not covered because of a formulary exception, step therapy, dosage limitation, or therapeutic substitution.
Here's how to navigate that process.
Checking the drug
Start by checking the plan's list of covered drugs. The Rx Plan number can be found on the front of the patient’s ID card.
Select the Rx Plan number here, to view the drug list:
A1/A2 B3 B4 E1/E3 E1/E4 E4 HMO M1 M2 M4
Check the drug list for the drug you prescribed, under its brand or generic name, to see whether a review is needed for that drug. Look for these labels: PA for prior authorization, QL for quantity limit, or ST for step therapy.
For instance, medications for certain conditions—such as migraines, diabetes, or high blood pressure—may need to meet certain requirements before a prescription is covered.
If an approval is needed, you or the pharmacy needs to contact us with that request. There are several ways to submit it:
- Calling our Pharmacy Services Center at 888-261-1756.
- Using electronic prior authorization (ePA) in the electronic health record or by visiting CoverMyMeds or ExpressPAth.
- Completing and faxing the Prior Authorization form.
- Checking our pre-approval drug list to learn more about our requirements and policy and to generate a partially completed fax form.
Type in the name of the drug to view pre-approval criteria, the drug's corresponding medical policy, and a link to an online fax form.
Chart Notes Required:
Type of Requirement:
Quantity Per Fill:
If the medication is urgently needed, sometimes a pharmacy can request a one-time emergency override for up to a 7-day supply.
We review most standard requests within 5 calendar days. If we need additional information, the review could take longer. If you mark the request as urgent, we typically handle these within 48 hours, whether or not adequate clinical information is available
to make a decision. If there's not sufficient clinical information to approve the request, it may be denied.
Once the medication is reviewed, we fax a decision to the requesting provider and send the patient a confirmation letter about the drug coverage decision. If the request is approved, the medication is covered by prescription benefits and can be filled
at the pharmacy. If the request is denied, the medication is not covered by the prescription benefits. You should then talk to the patient about choosing a different drug that is covered.
Requesting a formulary or pharmacy exception
A formulary exception review is required if the Rx Plan listed on the member’s ID card is M1, M2, or M4 and they have been prescribed a drug that is not on that list of covered drugs. For these drugs, submit the Pharmacy Exception
Request form by fax.
If the member is covered by a Washington state fully insured plan, the prescription may be subject to a set of guidelines and rules (formulary exception, step therapy, dosage limitations, or therapeutic substitution) that consider whether that drug is
appropriate for treating them and their condition. If the prescription is rejected under these guidelines, you may request an exception by submitting the Pharmacy Exception
Request form by fax. For these pharmacy exception reviews, we apply this medical policy as of January 1, 2021.
We review most standard formulary and pharmacy exception requests within 72 hours and urgent requests within 24 hours. If we need additional information, the review could take longer.
Pharmacy management information