Do I need approval before having a service or procedure done?
In some cases, yes. We require a preauthorization when specific services, supplies and procedures must be approved by us before the services are received.
It's especially important that the services are done with an in-network provider.
Contact our Customer Care Center if you have any questions:
Mon-Fri: 8 a.m. - 5 p.m. CT
Pharmacy Preauthorization Process
Preauthorization is required on certain drugs before you will be able to fill the prescription at the pharmacy. 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?
- The pharmacist enters your prescription information into the claims system.
- 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.
- Your provider will then need to fax 1-800-269-8561 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 your prescription for the appropriate co-pay (if applicable).
- If the preauthorization is denied: Your provider will contact you to determine alternate options.
Requesting a Preauthorization
If the drug is on the pharmacy preauthorization list located on AveraHealthPlans.com/PA, your provider must fax Avera Health Plans the preauthorization request with the proper form and supporting documentation.
NOTE: The preauthorization approval must be received BEFORE the pharmacy can fill your prescription.
If the drug is not listed on the pharmacy preauthorization list, you are not required to get a preauthorization.