Certain medications must undergo a clinical review to ensure they’re safe and effective before being approved for coverage. Prior authorizations may include quantity limits and/or step therapy, which requires a lower-cost drug to treat a condition before “stepping up” to a similar-acting, but more expensive drug. This process helps make sure medications are cost-effective and clinically appropriate. 

A PA listing is based on a variety of factors, including FDA-approved guidelines, standards of practice, dosing schedule, method of administration, and cost. 

Examples of medications subject to PA include: 

• Drugs that have dangerous side effects 
• Drugs with limited indications 
• Drugs that are subject to abuse and misuse 
• Drugs that are harmful when used in combination with other drugs 

Drugs with an excessive cost compared to equally effective, lower cost alternatives 

Before a GLP-1 medication is dispensed to you, it may have to undergo a 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.

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 Member Services team during business hours. 

Below are additional methods for contacting Member Services. 

Telephone Number: 800.334.8134 

Email: customercare@rxbenefits.com 

Hours of Operation: 7:00 am – 8:00 pm Monday – Friday CT; Closed – Saturday & Sunday 

A pharmacist reviewer will evaluate the exception request and make a coverage determination. If denied, the member or prescriber may appeal the decision and submit supporting documentation to an internal appeals team. A different reviewer will evaluate the request for reconsideration. If denied for reconsideration, a second appeal may be submitted and reviewed as an exception request for medical necessity. If the second appeal is denied, the member or their prescriber may request a third and final appeal, which will be reviewed by a third-party Independent Review Organization for external review. If the final appeal is denied, no further appeals are available.  

Appeal instructions are included in the denial notification. 

Yes. In the case where a PA is needed, a request can be made. The pharmacist will receive contact information that can be used by the patient, the pharmacy, or the prescriber to initiate the PA request. RxBenefits manages the review of requests from members or their providers via fax or through the online portal. Our clinical reviewers evaluate PA requests against specific clinical criteria and will make a coverage determination. 

Each PA time varies due to a number of factors. An initial PA can take up to 7 business days to process. 

Members can check the status of their PA by logging into their Member Portal.