2023 Prior Authorization and Step Therapy Criteria
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Prior Authorization Criteria
4 Tier Prior Authorization
5 Tier Prior Authorization
Step Therapy Criteria
4 Tier Step Therapy
5 Tier Step Therapy
Drugs Requiring Prior Authorization
The Retiree RxCare Prescription Drug Plan Formulary clearly indicates which prescription drugs require Prior Authorization (PA) before the prescription can be filled. Quantity limits on certain drugs will also be clearly identified on the Formulary. To obtain PA on a drug, your prescribing physician must submit a PA Form to Retiree RxCare Prescription Drug Plan, your doctor can call our Customer Care Center and request that a form be faxed, e-mailed or mailed to him/her. A decision will be made within three (3) business days and it will be approved or denied.
The prescribing physician will be notified by phone and by written letter with the Appeals Process information. The plan will also notify you (the insured) in writing within 72 hours explaining the reason for the denial and will provide information on your rights to appeal any decision about your Medicare Part D Plan benefits.
If your request is approved by the Plan, the pharmacy you are using will be notified immediately and your prescription will be filled. An override and expiration date of the approval will be entered into the Plan’s adjudication system so you will be able to fill that particular prescription without delay until the approval’s expiration date.
Reasons Why a Prescription May be Rejected by The Pharmacy
- The drug is not on the Part D plan’s Formulary
- A physician did not receive prior approval from the Part D plan for the prescribed medication
- The specific drug dosage, method of administration (liquid verses pill) or type (generic versus brand name) is not on The Plan’s Formulary
- A previously covered drug is no longer on The Formulary
- The pharmacy filling the prescription is not within the Part D plan’s network
- The prescribed medication is not a Part D-covered drug
You may request a copy of the plan's Policies and Procedures at any time by contacting the Plans’ Customer Care center at 855-693-3921,
Monday through Friday from 8:00 AM to 8:00 PM (Eastern).
If you or your prescriber would like to initiate the Prior Authorization process, please contact our Clinical Department at 877-274-7871 (TTY/TDD call 711)