Prior authorization is required for certain medications to be covered by HealthChoice and for tier exceptions. The prior authorization process helps establish that a particular case meets clinically driven, medically relevant criteria before HealthChoice approves the medication for coverage at the appropriate tier.
Providers who request prior authorization must follow this process:
- The provider’s office must call the pharmacy benefit manager (PBM). Please have the member ID number, medication name and fax number ready.
- The PBM will do one of two things:
- Fax a prior authorization form to the provider’s office. The provider must complete this form.
- May be able to take the required information verbally over the phone. The representative will ask the necessary questions and record the answers given.
- Once their review is complete, the PBM sends notification of the review results to the member and the provider.
- If the medication is approved for coverage, the PBM loads the approval into their system within 24 to 48 hours. Written notification of the approval is faxed to the provider and sent to the member within 24 to 48 hours. If the prior authorization is not approved, written notification is faxed to the provider and sent to the member within 24 to 48 hours, along with information for appealing the denial.
For additional information about the HealthChoice pharmacy benefits, reference the HealthChoice High, High Alternative, Basic and Basic Alternative Plans and High Deductible Health Plan Handbook at https://omes.ok.gov/services/employees-group-insurance-division/benefit-coordinator/handbooks or visit the pharmacy benefits information page at https://omes.ok.gov/services/healthchoice/member/pharmacy-benefits-information.