Commercial - Pharmacy Program |
Pre-Authorization Requirements
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:
1. Member’s name, address, and ConnectiCare ID number;
2. Provider name, address and phone number;
3. Drug, strength, dosage form and directions;
4. Indication for use;
5. Anticipated length of therapy; and
6. Dose and frequency of treatment for physician administered drugs
7. Information to support request (drug history and medical history)
8. 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
