Prior Authorization

Help your 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?

The Prior Authorization & Medical Necessity Determination (PA/MND) process is designed to ensure only medically necessary and appropriate prescription drugs are approved for coverage. PA/MND also encourages appropriate use of certain prescription drugs and actively monitors prescription drug use that may have serious side effects.

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. Employees 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.

What happens if an employee’s prescription needs prior authorization?

If a prescription requires prior authorization, your employee should:

  • Contact the prescribing physician and let them know 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.
  • Contact 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 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.

What happens if an employee tries to fill a prescription without the necessary prior authorization?

If the pharmacist enters a prescription into the computer, he or she will receive the message that a prior authorization is required and will not be able to fill the prescription until prior authorization is obtained through the steps above.