| Q: |
How can I check on the status of a drug prior authorization (PA)? |
| A: |
Call the Perform Rx Help Desk at 1-800-578-0898. |
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|
| Q: |
How long should it take to process my drug prior authorization
(PA)? |
| A: |
A response is usually faxed back
to the requester within 24 hours for non-urgent requests
and 4 hours for urgent requests. Authorizations are not
processed on weekends or holidays. |
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|
| Q: |
Who can complete a PA form? |
| A: |
A physician, nurse, pharmacist or other office
staff may complete a PA form. |
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|
| Q: |
How do I obtain a PA form? |
| A: |
Click
Here for a PA form (PDF File) |
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|
| Q: |
How can I request additions or deletions to the drug
list? |
| A: |
Complete the Request
for Drug List Review form and forward it to the Pharmacy
Department at Passport Health Plan at the address listed
on the form. Requests from pharmaceutical manufacturers
will not be accepted. |
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|
| Q: |
Are peak flow meters and spacers covered under the pharmacy
benefit? |
| A: |
Yes. A Passport Health Plan member can receive
these items from an out patient pharmacy with a valid prescription. |
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|
| Q: |
Are Over-the-Counter (OTC) medications covered under
the pharmacy benefit? |
| A: |
Yes. Certain OTC medications are covered.
A list of covered OTC
medications is located in the member section of the
Passport Health Plan web site. Members must have a valid
prescription to receive these products. Generic substitution
is required. |
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|
| Q: |
What can delay the processing of a PA? |
| A: |
Incomplete or unclear information on the form
can delay processing of a PA. Please print clearly. Make
sure the member name, Passport ID number and date of birth
are on the form. Contact information for the submitter (both
phone number and fax numbers including area code) is essential.
Please use one form per drug request. Provide clinical information
that relates only to the drug requested. Be clear and specific
in your request. |
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|
| Q: |
Who makes drug PA decisions? |
| A: |
The initial review is performed at Perform
Rx by pharmacy technicians. The request is compared to authorization
criteria that have been developed by Passport Health Plan.
If the request does not meet criteria, the request is forwarded
to a registered pharmacist for second review. Additional
information may be requested from the submitter. If a pharmacist
cannot approve the request, it is forwarded to a Passport
Health Plan Medical Director for a decision. All denials
are made by a physician licensed in Kentucky. |
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|
| Q: |
What are the types of PA decisions? |
| A: |
| Approved: |
A PA request has been approved for reimbursement. |
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|
Approved as
Modified: |
A PA request has been modified from
the original request by approving for a different
therapeutic alternative or different dose. Reimbursement
is approved for the modification. The original request
is not approved without further medical justification. |
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|
| Deferral: |
The final PA action has not been decided.
Additional information or clarification is required.
A response from the provider(s) for requested information
is required for final determination of PA action. |
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|
| Denial/Denied: |
A PA request has not been approved for
reimbursement. These decisions may be appealed to
Passport Health Plan. |
|
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|
| Q: |
How are drug list decision made? |
| A: |
Drug list decisions are recommended by Passport
Health Plan's (PHP) Pharmacy Committee. The Pharmacy Committee
is a sub-committee of the Quality Medical Management Committee
(QMMC) and provides direction to and oversight of pharmaceutical
care issues concerning all members. The Pharmacy Committee
is responsible for the review and approval of formulary
functions (i.e. prior authorization (PA) of pharmaceuticals),
clinical guidelines for pharmaceutical treatment, drug monitoring
programs, as well as quality and utilization management
issues relating to pharmaceutical care. The Pharmacy Committee
is charged with accountability for cost-benefit analysis
of drugs/drug categories. The Pharmacy Committee also reviews
the results of drug utilization review (DUR) audits or reports,
and reviews practitioner prescribing profiles. |
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|
| Q: |
Does Passport Health Plan have an emergency dispensing
procedure? |
| A: |
Yes. Since the PA department is not available
at all times there is a process for obtaining medication
on an emergency basis. The pharmacist may process an emergency
supply if in their clinical judgement, it is in the best
interest of the patient. The maximum quantity that can be
dispensed is either a 5-day supply or 25 units (tablets
or capsules). This applies only to certain categories of
drugs for which an emergency supply may be dispensed include
such as: analgesics, anti-asthmatics, anti-convulsants,
anti-diabetics, anti-infectives, anti-neoplastics, anti-parkinsonian
agents, anti-rejection agents, cardiovascular and thyroid
agents. |
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|
| Q: |
How can I find out what drugs require prior authorization? |
| A: |
The most commonly prescribed drugs are listed
on the Preferred
Drug List located on this web site. The complete
list also on this web site, contains all products. Both
lists are organized by therapeutic drug class |
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|
| Q: |
How can I avoid needing a prior authorization? |
| A: |
Use the Preferred
Drug List as a guide when making drug therapy decisions
for Passport members. If an entire drug class is listed
as requiring prior authorization, write for the preferred
product within that class to avoid needing to change the
order if the authorization is approved as modified. |
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|
| Q: |
Is the physician’s signature required on the form? |
| A: |
No, it is optional. |
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|
| Q: |
Is pharmacy contact information required on the form? |
| A: |
No, it is not essential, however, Perform
Rx contacts both the prescriber and pharmacy of the decision.
Providing pharmacy contact information may prevent delays
in dispensing the drug. |
