Prior Authorization
What is prior authorization or PA/MND?
Certain drugs require Prior Authorization or Medical Necessity Determination (PA/MND) before coverage is approved. The PA/MND process is designed to assure that only prescription drugs that are medically necessary and appropriate 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 and helps keep the cost of prescription drug therapy affordable for you.
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 your 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 your prescriptions 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.
What can I do if my prescription needs prior authorization?
Here are the steps you can take as a member if you find a prescription requires prior authorization:
- Contact the prescribing physician and let them know that your medication requires a prior authorization.
- Ask how long it usually takes for your physician to complete the appropriate forms to initiate the prior authorization process.
- You may also contact pharmacy member services, using the toll free number on the reverse of your member ID card, to see if there are additional steps you need to take depending on your pharmacy benefit plan.
- Allow the doctor’s office and Horizon Blue Cross Blue Shield of New Jersey enough time to complete this process.
- Check back with the pharmacy to see if the prior authorization was approved.
- If your medicine is not approved, please refer to the written authorization you have received or will receive in the mail. It includes all the relevant information necessary to continue the process.
Which medications are subject to PA/MND?
This list of medications is subject to PA and/or MND criteria. This list changes frequently and is periodically updated. Please register or sign in to Member Online Services to get the most up-to-date information relevant to your health or prescription drug plan.
