Prior Authorization

Help your clients and their employees understand prior authorization, quantity limits and other unique restrictions on some medications and the steps they may need to take when filling a prescription.

What is Prior Authorization or PA/MND?

Certain drugs require Prior Authorization & Medical Necessity Determination (PA/MND) before coverage is approved. The PA/MND process is designed to assure only medically necessary and appropriate prescription drugs are approved for coverage. PA/MND also:

  • Encourages appropriate use of certain prescription drugs
  • Promotes generally accepted treatment protocols
  • Actively monitors prescription drug use that may have serious side effects
  • Helps keep the cost of prescription drug therapy affordable

When does a prescription require PA/MND?

Eligibility for coverage of some medications cannot be determined from the information received with ordinary claims transactions. Therefore, there may be times when additional information is requested from a physician to clarify eligibility for coverage. Under these circumstances, the physician will need to submit a request for prior authorization or a request for quantities above the plan limit. To encourage appropriate prescription drug usage, enhance drug therapy and reduce costs, certain drugs may have limits established by the FDA. These can include limits on gender or age of the patient, as well as the quantity of the drug that can be dispensed over a given period of time, known as a Quantity Limit or QL. Prior authorization is often required when a prescription falls outside these limits.

How does the PA/MND process get started?

When pharmacists enter a prescription into their computer systems, they receive the message that a prior authorization is required. It is the physician’s responsibility to contact the prior authorization department and initiate the process. If a prescription requires prior authorization, the member should:

  • Contact the prescribing physician and let them know that the medication requires a prior authorization.
  • Ask how long it usually takes for the physician to complete the appropriate forms to initiate the prior authorization process.
  • Call Pharmacy Member Services, using the toll free number on the reverse side of their member ID card, to see if there are additional steps that need to be taken, depending on the particular pharmacy benefit plan.
  • Allow the doctor’s office and Horizon BCBSNJ enough time to complete this process.
  • Check back with the pharmacy to see if the prior authorization was approved.

If the medicine is not approved, refer to the written authorization that was received or will be received in the mail. It includes all the relevant information necessary to continue the process.

Which medications are subject to PA/MND?

The list of medications that are subject to PA and/or MND criteria changes frequently and is periodically updated. Members should register or sign in to Member Online Services to get the most up-to-date information relevant to their health or prescription drug plan.