August 1, 2019
The Premera pharmacy pre-approval program is designed to promote appropriate drug selection, length of therapy, and use of specific drugs while improving the overall quality of care. We use criteria based on clinical best practices and approval by an independent Pharmacy & Therapeutics Committee.
The program includes four types of reviews: formulary exception (non-formulary), quantity limit, step therapy, and pre-approval. Our Rx Search tool can be used to see if a drug falls into one or more of these categories.
How long does a review take?
- Standard: We review most standard requests within 72 business hours. If we need additional information, the review could take longer.
- Urgent: We typically handle these within 24 hours. If there's not enough clinical information to approve the request, it may be denied.
- Electronic Prior Authorization (ePA): Approvals can be returned within minutes. To submit an ePA, use your electronic health record or visit CoverMyMeds® or ExpressPAth®.
What happens after the review?
Once the medication is reviewed, we fax a decision to the requesting provider and send the member a confirmation letter about the prescription coverage decision.
- If the review is approved, the medication is covered by the member's prescription benefits and can be filled at the pharmacy.
- If the review is denied, the medication isn't covered by the member's prescription benefits. It’s suggested that the member should talk to their provider about choosing a different drug that's covered.
To request a review, the pharmacy or the provider needs to contact our Pharmacy Services Center at 888-261-1756 or fax in a drug-specific online form. Learn more about our pharmacy benefits, drugs requiring approval, and leveled drug benefits.