Some drugs, due to their narrow indication, potential for misuse, or high cost require pre-authorization to ensure appropriate access and use. Before these drugs will be covered, the physician must forward the medical rationale for the drug selection to Pharmacy Services. The drug will be approved or denied for coverage based on criteria established and approved by the P&T Committee. Some drugs within the pre-authorization program require other medications be used prior to approval (Step Therapy).
Drugs on the pre-authorization list are rejected when submitted for payment at the pharmacy unless they have been prior authorized by ConnectiCare. (In such situations, when a member pays out-of-pocket, the member may seek reimbursement approval for benefits through ConnectiCare’s Pharmacy Services Department.) The member’s physician should complete the applicable Prior Authorization Form and fax it to Pharmacy Services. The request will be reviewed by a ConnectiCare pharmacist and a decision will be communicated within two business days.
To request pre-authorization, please complete a Pharmacy Pre-authorization Form and return to Pharmacy Services via fax to 860-674-2851 or 1-800-249-1367.
The following information should be supplied when requesting pre-authorization:
Member’s name, address, and ConnectiCare ID number;
Provider name, address and phone number;
Drug, strength, dosage form and directions;
Indication for use;
Anticipated length of therapy; and
Dose and frequency of treatment for physician administered drugs
Information to support request (drug history and medical history)
Reason for request (e.g., allergy, failure with other medication)
Fax to: (860) 674-2851 or 1-800-249-1367
Please refer to the list of drugs requiring pre-authorization on the following page.
What happens next?
ConnectiCare’s pharmacist will review the request for authorization and make the determination.
When a request for authorization is denied, ConnectiCare will notify the physician and member in writing, including: the reason for the determination and clinical rationale, if any; instructions on how to initiate an appeal of the decision; and, notice of the availability of the medical necessity criteria referenced in the decision.
ConnectiCare’s Pre-authorization Drug list
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PPM/7.08 |