Preauthorizations

Avera Health Plans requires prior authorization on certain medical services and prescription drugs that are covered under the medical benefit.

Urgent Requests

If your request for preauthorization is urgent, meaning a delay could jeopardize the patient’s life, health or ability to regain maximum function or would cause severe pain that could not be adequately managed without the requested care or treatment, we will respond within 24 hours.

To submit an urgent request, call 888-605-1331.

How It Works

As the provider, you are responsible for submitting preauthorization requests to us for approval. Members do not request preauthorization. To submit a preauthorization request:

  1. Check the preauthorization tools on our website for specific types of drugs, medical procedures and imaging services.
  2. Complete the necessary form(s) and gather documentation. If there’s a designated form, use that – otherwise refer to the general Preauthorization Request Form (pdf)
  3. Submit the appropriate form and documentation to us via fax at 800-269-8561.

What happens if preauthorization isn't received for medical care?

If a member’s medical care or procedure fails to receive a required preauthorization, the member will be responsible for paying the entire billed charge.

What happens at the pharmacy?

  1. The pharmacist enters the member’s prescription information into the claims system.
  2. If a drug requires preauthorization, the pharmacist will receive a message that a preauthorization is required. In most cases, the pharmacy will notify you as the provider about this requirement.
  3. As a provider, you need to fax 800-269-8561 or send a secure email to Pharmacy@AveraHealthPlans.com with the supporting documentation for Avera Health Plans to begin the preauthorization process. (This may take up to 72 hours to complete.)

If the preauthorization is approved: The pharmacy will be able to process the prescription for the appropriate co-pay (if applicable).

If the preauthorization is denied: As a provider, you will need to contact the member to determine alternate options.

Medical and Imaging Services

Need to check if preauthorization is needed for certain medical care or procedures – or for imaging services?

  1. Enter the complete 6-digit group number from our member ID cards that begin with a 99, and for our new member ID cards, the “A” followed by a 7-digit number. (For UMR, enter the 9-digit with no dash or space).
  2. Review the results, which will display services requiring preauthorization and what’s not covered. You’ll also find related preauthorization forms and instructions to submit to us.

Prescriptions & Pharmacy

Certain drugs require review and preauthorization in order for pharmacy benefits to be approved for a member. Check our preauthorization drug lists below.

Chemotherapy Drugs

All chemotherapy drugs require preauthorization.

See List

Medical Drug Preauthorization

These drugs are covered by the medical benefit only.

See List

Pharmacy Drugs

These drugs are covered by the pharmacy benefit only.

See List

Self-Injectable Drugs

These drugs are covered by the pharmacy benefit.

See List

Specialty Drugs

Some are only available through the specialty pharmacy network.

See List

Step Therapy

Some step therapy drugs require preauthorization.

See List

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