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.
Drugs on the pre-authorization list are denied 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 must apply for pre-authorization for the specific patient and for a specific drug and dose.
To request pre-authorization, please complete a Pharmacy Pre-authorization Form, found in section 14, Forms or on our website at www.connecticare.com and return to Pharmacy Services via fax to 860-674-2851.
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
Frequency of visits for chemotherapy
Information to support request (drug history and medical history)
Reason for request (e.g., allergy, failure with other medication)
Fax to: (860) 674-2851
Please refer to the list of drugs requiring pre-authorization on the following page.
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This list is subject to change. Please visit www.connecticare.com or call Provider Services at 1-800-828-3407 for the most current list. |
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 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 clinical review criteria referenced in the decision.
The following drugs require pre-authorization by ConnectiCare’s Pharmacy Services Department:
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Aciphex (Use Prilosec OTC) Actiq (fentanyl citrate lozenge) Actonel (Use Fosamax) Advicor (Use simva-, prava-, lovastatin first) Agrylin (anagrelide HCL) Allegra /Allegra D (Use loratadine OTC first) Alpha1-Proteinase Inhibitors (All) Aldurazyme Alimta Altoprev (Use simva-, prava-, lovastatin first) Apokyn Aralast Ambien CR (Use Ambien) Amevive Androderm Androgel Aranesp Aricept (PA <50 years old only) Avastin (bevacizumab) Avodart (PA < 55years old only) Avonex Beconase AQ (Use generic flonase first) Betaseron Bexxar Blood Clotting Factors (All) Boniva Injection Boniva tablets (Use Fosamax) Botox Bravelle Buphenyl Byetta Campral Cardura XL (Use generic doxazosin first) Celebrex Cerezyme Cesamet Cetrotide Chantix Cholestrol Lowering Drugs: Advicor, Altoprev, Crestor, Lescol/XL, Liptor, Vytorin Clarinex/D (Use loratadine OTC first) Clomid Compounded Medications Contraceptives (if excluded by group) Copaxone Crestor (Use simva-, prava-, lovastatin first) Crinone Dacogen Detrol/LA (Use oxybutynin IR/XL first) Elaprase Elidel (PA <2 years of age) Eloxatin (oxaliplatin) Enbrel (etanercept) Enablex (Use oxybutynin IR/XL first) Erbitux (cetuximab) Euflexxa Exelon (PA <age 50 only) Exjade Exubera Fabrazyme Fentanyl Citrate Fentora (fentanyl) Fexofenadine (Use loratadine OTC) Fluoxetine 40mg capsules Flolan (epoprostenol) Follistim AQ Food Supplements Forteo Fuzeon Ganirelix Genotropin Gleevec (imatinib) Gonal-F Growth Hormones (All) HCG (chorionic gonadotropin) Herceptin Humatrope Humira (adalimumab) Hyalgan (sodium hyaluronate) Increlex Infergen Injectable Drugs (All): excluding insulin Interferons (All) Infertility Medications (All) Intron-A IPlex Iressa IV Immune Globulin (IVIG) Kineret Klonopin Wafers (Use clonazepam tablets) Lamisil Lescol/XL (Use simva-, prava-, lovastatin first) Lipitor (Use simva-, prava-, lovastatin first) Lotronex Lucentis Lunesta (Use Ambien) Luveris Lyrica (Step Care) Macugen Menopur Mepron (atovaquone) |
Mirena (levonorgestrel-releasing IUD) Myobloc Myozyme Naglazyme Namenda (PA <50 years old only) Nasacort AQ (Use generic flonase or Nasonex first) Nasal Corticosteroids (Use fluticasone or Nasonez first) Nasarel (Use generic flonase or Nasonex first) Nexavar Nexium (Use Prilosec OTC) Niravam (use generic alprazolam) Norditropin Novarel Novoseven Nutropin/AQ Nuvigil Omacor Omnaris (Use generic flonase or Nasonex first) Orencia Orfadin Orthovisc Ovidrel Oxandrin Oxytrol (Use generic oxybutynin IR/XL first) Pegasys Peg-Intron Penlac (ciclopirox) Preos Prevacid (Use Prilosec OTC) Prevacid Naprapac Prialt Prilosec (Use Prilosec OTC) Prolastin Proleukin (aldesleukin) Proscar (PA < 55 years old only) Protonix (Use Prilosec OTC) Protopic (< 2 years of age) Provigil Raptiva Razadyne (PA < 50 years old only) Rebif Regranex Remicade Remodulin Repronex Retisert Revatio Revlimid Rhinocort Aqua (Use generic flinase or nasonex first) Ribavirin Rituxan Saizen Sanctura (Use oxybutynin IR/XL first) Singulair (Use loratadine OTC first for allergic rhinitis) Smoking Cessation Medications Somavert Sporanox (itraconazole) Sprycel Steroids, Anabolic (i.e., Nandrolone) Striant Strattera Supartz Sutent Symlin Synagis (palivizumab) Synarel (nafarelin) Synvisc (hyaluronate sodium) Tarceva Temodar Testim Testosterone (All) Thalomid Thelin Tracleer Travel Medication: including Malarone, Larium and Aralen Tysabri Vectibix Velcade Ventavis Vesicare (Use oxybutynin IR/XL first) Vidaza Vivaglobulin (SQ Immuneglobulin) Vytorin (Use simva-, prava-, lovastatin first) Weight Loss Medication: (if covered by your plan); i.e, Meridia, Xenical, Ionamin, Tenuate, etc Wellbutrin SR/XL Xanax XR (use generic alprazolam) Xeloda Xolair Xyrem (Sodium Oxybate) Zanaflex Caps (Use tablets) Zantac gel dose (Use tablets) Zavesca Zegrid (PA for age > 15 y/o) (Use Prilosec OTC) Zemaira Zevelin Zolinza Zyban Zyrtec/Zyrtec D (Use OTC loratadine first) |
Step Care: Authorizations for these drugs will be processed automatically when established criteria to first try Tier 1 & Tier 2 options have been satisfied.
* Certain specialty prescription drugs require pre-authorization and must be filled through specialty pharmacies. See Speciality Prescription Drugs.
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PPM/6.07 |