Prior Authorizations
A prior authorization (PA) review is used for a wide variety of medications to confirm that medication is being prescribed for its intended use based on FDA guidelines. These reviews are meant to ensure certain prescriptions meet specific criteria before they are covered by a pharmacy plan. This process helps manage the safe and cost-effective use of medications.
Typically, there are two scenarios that result in a claim requiring a PA to be approved:
Clinical PAs
Initiated by the prescriber to cover medications not typically included in the pharmacy plan.
Administrative PAs (Overrides)
Used to resolve claim rejections at the pharmacy for medications usually covered by the pharmacy plan.
When a PA is required, a pharmacist may provide a temporary supply of the medication, and the member will receive instructions and forms to complete the authorization process.
Quick Links
PA Form Download
Download and complete the PDF form to start the PA process.
Submit a PA Form
Submit your completed PA form here for prompt processing.
Check Your PA Status
Check the status of your PA request for real-time updates
Member FAQs
If you have a question about your PA, log into your member portal to check the status or use the chat feature to contact the customer care team during business hours.
Below are additional methods for contacting customer care.
Telephone Number: 800.334.8134
Email: customercare@rxbenefits.com
Hours of Operation: 7:00 am – 8:00 pm Monday – Friday CST; Closed – Saturday & Sunday
If denied, the member or prescriber may appeal the decision and submit supporting documentation (chart notes/documentation) to an internal appeals team. A second, different pharmacist reviewer will analyze the appeal. If denied again, the member or prescriber may appeal a final time, based on medical necessity, to a third-party Independent Review Organization for an external review. If denied a third time, there are no further appeals.
Appeal instructions are always included in the denial notification.
Each PA time varies due to a number of factors. An initial PA can take up to 7 business days to process.
Providers can access PromptPA for status updates, even if they did not submit/initiate the PA in PromptPA. They just need the Member ID Number, Member Name, Date of Birth, and EOC# to check status. Members can check the status of their PA by logging into their member portal.
Before a GLP-1 medication is dispensed to you, it may have to undergo a prior authorization (PA) review. These reviews are used for a wide variety of medications to confirm that the medication is being prescribed for its intended use based on FDA approval guidelines and standards of care.
If your plan requires a PA for GLP-1s approved for Type 2 diabetes, you won’t be able to fill your GLP-1 prescription immediately. If this happens, call your prescribing doctor and let them know your medication requires a PA – they’ll need to file paperwork for your prescription to confirm a Type 2 diabetes diagnosis. If your plan covers GLP-1s approved for weight management and requires a PA for them, your doctor should file PA paperwork confirming a diagnosis related to weight management.
Your prescription will be approved or denied based on the information your doctor provides, and you’ll be notified of the decision by mail.
View or download this flyer to understand GLP-1 drugs, shortages, and coverage.
