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Are you shopping for Avera Health Plans insurance? Check out our prescription drug coverage details for non-members.

What's Covered and How Much?

As a member, the amount you pay for a prescription depends on the drug's tier level and the benefit level associated with your plan.

Prescription Preauthorizations

How do you know if you need approval first?

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.

What drugs need preauthorization?

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.

What is the preauthorization process?

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.

What happens at the pharmacy?

  1. The pharmacist enters your prescription information into the claims system.
  2. If a drug requires preauthorization, your pharmacist will receive a message that a preauthorization is required. In most cases, the pharmacy will notify your provider of the requirement.
  3. Your provider will then need to fax 800-269-8561 or send a secure email to Pharmacy@AveraHealthPlans.com with the supporting documentation for us to begin the preauthorization process. (This may take up to 72 hours to complete.)

What's the process for step therapy drugs?

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. (This may take up to 5 calendar days to complete).
    • 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.

How does a provider request preauthorization?

As an Avera Health Plans member, you aren’t able to request preauthorization for your prescription drug. Your provider needs to submit this request with the proper form and supporting clinical documentation.

  • The provider must review the pharmacy preauthorization list available to them via our provider resources.
  • If the drug is listed on the drug formulary, but is not on the pharmacy preauthorization list, pre-approval is not required.
  • For drugs on the list, preauthorization approval is required BEFORE the pharmacy can fill your prescription.

Tips to Maximize Your Pharmacy Benefits

  1. Choose a participating pharmacy.
  2. Pay the pharmacy your prescription’s co-pay and co-insurance. If the retail cost is less than the co-pay, you’ll pay the full retail amount.
  3. Show your member ID card at the pharmacy each time you fill a prescription.
  4. Use generic drugs whenever possible.
  5. Get your prescriptions by mail order. Fill out the Avera mail order request form to get started.

Need Something Else?

See all of our member resources online.

Member Resources Member Portal

Or contact our Customer Service team.

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