Drug Preapproval
For some drugs that your provider prescribes, LifeWise Assurance Company reviews the circumstances before deciding whether to cover the drug.
This approval process can be triggered by several different situations:
- Prior authorization: The drug is on your plan’s drug list, but it requires an authorization before the prescription is covered.
- Quantity limit: The drug is on your plan’s drug list, but we limit the amount of the drug that we will cover.
- Step therapy: The drug is on your plan’s drug list, but we require that you first try a different drug before authorizing the drug prescribed.
- Formulary exception: The drug is not on your plan’s drug list, but your provider has prescribed it.
- Pharmacy exception: You are covered by a Washington state fully insured plan, and your prescription was not covered because of a formulary exception, step therapy, dosage limitation, or therapeutic substitution.
Approvals and exceptions
Checking your drug
Check your plan’s drug list for the drug you were prescribed, under its brand name or generic name. See whether a review is needed for that particular drug. Look for these labels: PA for prior authorization, QL for quantity limit, or ST for step therapy.
GAIP drug list (B3)
ISHIP drug list (M4)
Requesting approval
If an approval is needed, your provider or pharmacy needs to contact us with that request. There are several ways they can submit it:
- Calling our Pharmacy Services Center at 888-261-1756.
- Using electronic prior authorization (ePA) in the electronic health record or by visiting CoverMyMeds or ExpressPAth.
- Completing and faxing the Prior Authorization form.
If the medication is urgently needed, sometimes a pharmacy can request a one-time emergency override for up to a 7-day supply.
We review most standard requests within 5 calendar days. If we need additional information, the review could take longer. If your provider marks your request as urgent, we typically handle these within 48 hours, whether or not adequate clinical information is available to make a decision. If there’s not sufficient clinical information to approve the request, it may be denied.
Once the medication is reviewed, we fax a decision to the requesting provider and send you a confirmation letter about the drug coverage decision. If the request is approved, the medication is covered by your prescription benefits and can be filled at the pharmacy. If the request is denied, the medication is not covered by your prescription benefits. You should then talk to your provider about choosing a different drug that is covered.
Requesting a formulary or pharmacy exception
A formulary exception review is required if you have been prescribed a drug that is not on that list of covered drugs. For these drugs, submit the Pharmacy Exception Request form by fax.
If you are covered by a Washington state fully insured plan, your prescription may be subject to a set of guidelines and rules (formulary exception, step therapy, dosage limitations, or therapeutic substitution) that consider whether that drug is appropriate for treating you and your condition. If your prescription is rejected under these guidelines, your provider may request an exception by submitting the Pharmacy Exception Request form by fax. For these pharmacy exception reviews, we apply this medical policy as of June 1, 2023.
We review most standard formulary and pharmacy exception requests within 72 hours and urgent requests within 24 hours. If we need additional information, the review could take longer.
Requesting a HIV PrEP (human immunodeficiency virus pre-exposure prophylaxis) drug cost share exception
If you have preventive benefits and you think your HIV PrEP drug should be available at no cost under your health plan, your provider may request an exception by submitting the Pharmacy Exception Request form by fax. For these pharmacy exception reviews, we apply this benefit coverage guideline. We review most standard exception requests within 72 hours and urgent requests within 24 hours.
Emergency fills for medications requiring preapproval
Medication list for emergency fills
The medication list for emergency fill to address immediate therapeutic needs is as follows: (Medications in addition to those listed below may be covered for Emergency Fill on a health plan by health plan basis).
- Antibiotics & Antivirals for acute infections
- Medications for mental health conditions
- Anticoagulant/Antiplatelet medication
- Antiemetics (for imminent Nausea and Vomiting)
- Anti-Rejection/Immunosuppression medication for post-transplant patients
- Antiretrovirals (continuing current therapy, not new starts except for emergency use)
- Cardiovascular medications for acute treatment only (e.g. antiarrhythmics, anti-hypertensives)
- Epinephrine injections
- Generically available, immediate release pain medication (does not include transmucosal immediate release fentanyl)
- Gout flare (acute) medications
- Insulin (continuing current therapy, not new starts)
- Naloxone
- Non-OTC pediculocides-lice and scabies treatments
- Rescue Inhalants and delivery support devices
- Seizure/epilepsy medications
- Triptans
High dollar medications for chronic conditions, e.g. oral oncology, hepatitis C, biologics, multiple sclerosis treatments, enzyme replacements, etc. are not consistent with the above definition of “immediate therapeutic needs” and thus would not be covered for emergency fill.
Also, an emergency fill will not be paid in the following situations:
- Non-contracted pharmacy
- Refill too soon
- Quantity limitation exceeded
- Yearly maximum met
When are emergency fills appropriate?
Emergency Fills are appropriate in those circumstances where a patient presents at a pharmacy with an ‘immediate therapeutic need’ for a prescribed medication that requires a pre-authorization due to formulary or other utilization management restrictions.
- Immediate therapeutic needs are those where passage of time (i.e. the timeframe required for an Urgent Review) without treatment would result in imminent emergency care, hospital admission OR might seriously jeopardize the life or health of the patient or others in contact with the patient
- Emergency Fill is a short term dispensed amount of medication that allows time for the processing of a pre-authorization request. Only the emergency fill dosage of the medication will be approved and paid.
The dosage of the Emergency Fill must either be the minimum packaging size that cannot be broken (e.g. injectable), or the lesser of a 7-day supply or the amount as prescribed. (Depending upon their policies, Health Plans may exceed this baseline dispensing amount.) In the event the medication is to be continued for treatment beyond the emergency fill authorization, health plans may apply formulary or utilization management restrictions that will be reviewed following the health plans’ standard procedure.
What is the process for getting approval and payment of an emergency fill?
When a currently eligible member of the health presents at a contracted dispensing pharmacy with an immediate therapeutic need and a corresponding prescription from their provider for a medication requiring a pre-authorization that is specified on the list,
- If the health plan has 7 day x 24 hours availability to respond to phone calls from a dispensing pharmacy but the health plan cannot reach the prescriber for full consultation, an emergency fill will be authorized for dispensing.
-OR-
- If the dispensing pharmacy cannot reach the health plan’s pre-authorization department by phone as it is outside of that department’s business hours, an Emergency Fill can be dispensed by the pharmacy and will be approved and paid.
The health plan’s Emergency Fill policy (which must be on their web site) will outline their process by which the dispensing pharmacy can secure payment for emergency fill. Two typical processes are:
- The dispensing pharmacy will be given a code that can be submitted with the claim that designates the dispensed medication as an emergency fill and will authorize payment.
- The dispensing pharmacy will contact the health plan’s pre-authorization department within 2 business days to inform them of the Emergency Fill so that a claim for the dispensed medication can be retrospectively submitted and paid.