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When you take a prescription to a network pharmacy, the pharmacy will tell you if Passport Advantage will cover the medicine.
There are many reasons that we might not cover a medicine. If we do not cover a medicine, your provider might have to ask us:
- For approval for you to get the medicine. This is called asking for authorization.
- For an exception to one of our rules, which include:
- You must use a generic version of the medicine.
- You can only get a certain amount of the medicine.
- You must try a different medicine first.
- To cover a medicine that is not in our formulary.
In all these situations, your pharmacy should call your provider or PerformRx (our pharmacy benefit manager) to decide what to do.
- If the pharmacy cannot reach your provider, the pharmacy will give you a temporary supply of the drug that your provider prescribed. You will receive a 5-day supply of the drug if it is one that you have never received before or have not taken in a while. You will receive a 15-day supply if it is a medicine that you are currently taking. Passport Advantage will then call your provider to find out if he or she will prescribe a drug on the formulary, request an exception to the formulary, or request prior authorization.
- If the pharmacy does reach your provider and he or she refuses to prescribe a drug on the formulary, the pharmacy will give you a 5-day supply of the drug that your provider prescribed. Passport Advantage will then call your provider to explain how the provider can ask for an authorization or an exception to the formulary.
- If your provider would like to request an exception to the formulary or to request prior authorization, your provider should complete the Exception and Prior Authorization Form and fax it to PerformRx at 866-369-6038 for a standard request or 866-533-5491 for an urgent request.
- A PerformRx clinical pharmacist will review the form and decide whether or not to approve the request.
- If PerformRx agrees with your provider's request, we will notify your provider and your pharmacy so you get your prescription.
- If PerformRx does not agree with your provider's request, PerformRx will contact Passport Advantage. One of Passport Advantage's Medical Directors will consider the request.
- If Passport Advantage agrees with your provider's request, we will notify your provider and your pharmacy so you get the prescription. Prior authorizations last six months.
- If Passport Advantage does not agree with your provider's request, we will fax your provider a letter. We will also mail you a letter that tells you why we do not agree, and explain how you can ask us to review our decision.
- Your provider or pharmacy should call PerformRx at 1-866-533-5490 if they have any questions about this process.
If you live in a long term care facility, ask us to cover a medicine the same way we explain above. But, we will give you a temporary 31-day supply of the medicine.
To learn more about how you can ask us to review our decision, read our Appeals and Grievances Policy.
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