In some circumstances, our approval – or preauthorization – is required before you receive specific prescription medicines, in order for it to be covered by us. If you fail to receive a required preauthorization, you'll be responsible for paying the entire billed charge.
To find a list of drugs requiring preauthorization, log into the member portal or call 888-322-2115.
It's important to note that preauthorization does not guarantee benefits and that the preauthorization list is subject to change. Benefits are subject to all conditions of your individual health policy.
Our Pharmacy and Therapeutics Committee decides which drugs require preauthorization. Factors that are reviewed in making this determination include Food and Drug Administration (FDA) approved indications, manufacturer package guidelines, medical literature, accepted medical practice guidelines, safety and cost.
To find a list of drugs requiring preauthorization, log into the member portal or call 888-322-2115.
Step therapy is intended to use the most cost-effective and safest drug available for a specific medical condition.
- If you need step therapy drugs, your provider must prescribe certain drugs before trying another. Step therapy programs require your provider to prescribe Step One drugs before Step Two drugs.
- We realize the "first step" drug may not always be the best drug for you. If you used a Step One drug without getting the results you and your provider would like, your provider can request a step therapy review which may lead to an override.
What happens at the pharmacy?
- The pharmacist enters your prescription information into the claims system.
- If a drug is a Step Two drug, the pharmacist will receive a message about the step therapy requirements.
- The pharmacy will contact your provider.
Your provider can do one of the following:
- Prescribe a Step One drug.
- Request a step therapy override by faxing Avera Health Plans at 800-269-8561.
- If the override is approved: The pharmacy will fill your prescription for the appropriate co-pay or co-insurance.
- If the override is denied: Your provider will need to prescribe a Step One drug.
If you and your provider decide not to go through the override process, your provider can prescribe a Step Two drug, and you will pay the entire cost of the prescription.
Specialty drugs are high-cost medications used to treat complex, chronic conditions. These drugs often require special handling, administration or monitoring. Your prescribing health care provider can tell you if your prescribed drug is classified as a specialty drug. To find a list of drugs requiring preauthorization, log into the member portal or call 888-322-2115.
You can check your plan's drug formulary or contact our customer care team to verify coverage for your specific specialty medication. Formularies may be updated periodically, so it's essential to stay informed about any changes.
Many specialty drugs do not have generic equivalents due to their complexity. Check with your health care provider or pharmacist to determine if a generic version is available or if there are alternative treatment options.
If your medication is denied coverage, your provider and pharmacy will work together to find a solution for an alternative medication.
