GHP_DrugPA

Back to pharmacy menu

DRUG PRIOR AUTHORIZATION

To promote the most appropriate utilization, selected high-risk or high-cost prescriptions or devices have quantity limitations in place or require prior authorization by our Pharmacy Director.

Prior authorization criteria are established by our Pharmacy & Therapeutics Committee with input from Gundersen Health Plan physicians and consideration of the current medical literature. Upon enrollment and upon request, members receive a list of drugs which need prior authorization. These medications are identified within the Formulary (complete a search by accessing the link) and have a "PA" following the drug name.

If a medication is required that is not routinely covered, the provider may present medical evidence to obtain an individual patient exception by submitting a prior authorization request.

Prior authorization forms should be completed and directed to:

Gundersen Health Plan
Pharmacy Department NCA2-01
1900 South Avenue
La Crosse, WI 54601

Fax: (608) 775-8790
Telephone: (800) 897-1923 or (608) 775-8007

To obtain authorization for coverage of a non-covered prescription drug or device in an urgent care situation, the provider or pharmacy may contact our Pharmacy Department via telephone to obtain authorization within a medically appropriate time frame, but not to exceed 24 hours.

Drug Prior Authorization Process
Certain prescription drugs, as determined by the Gundersen Health Plan Pharmacy & Therapeutics Subcommittee, require prior authorization, or may be subject to quantity limits or step therapy. Prior authorization criteria are established with input from our plan physicians, pharmacy benefit manager and consideration of current medical literature. 

Provider authorization forms need to be completed by the healthcare provider and directed, by fax or mail, to Gundersen Health Plan Pharmacy Management.

Within 72 hours of receipt of a request, the member will be notified by phone, or in writing, of the prior authorization determination. If a provider fails to follow the health plan’s procedures for filing the prior authorization, the provider will be notified within five days upon receipt of the request. 

    To obtain coverage of a prescription requiring prior authorization in an urgent care situation, providers may contact Pharmacy Management at (800) 897-1923 or (608) 775-8007. The time frame for an urgent review and determination will not exceed 24 hours from receipt of the request.

    The Gundersen Health Plan provides the practitioner with information to understand and decide whether to appeal a decision to deny coverage. The following information is included in all denial notices:

    • The specific reason for the denial in understandable language
    • Reference to the specific plan provisions on which the denial is based
    • Instructions for filing a grievance/appeal regarding the denial and independent external review (if applicable)

    You may obtain a copy of the criteria, clinical guidelines, or benefit provisions used for making a decision. Please contact us by phone at (800) 370-9718 ext. 58022, or (608) 775-8022, or send your request to us at the address listed above. Gundersen Health Plan is staffed with a full time pharmacy director who is able to discuss medical necessity decisions. In the event the pharmacy director is unavailable, our medical director or an associate medical director can address questions regarding determinations.