What is the process for submitting Pharmacy PAs, and what pharmacy services require a PA?
Empower is committed to providing appropriate, high quality, cost-effective drug therapy to all of our members. Empower works with providers and pharmacists to ensure that medications used to treat a variety of conditions and diseases are covered. The plan covers prescription drugs and certain over-the-counter (OTC) drugs when ordered by an Empower physician. The pharmacy program does not cover all medications. Some drugs have a generic equivalent or a brand-name drug from a different manufacturer that is covered. Some medications require prior authorization or have limitations on age, dosage, maximum quantities, or any combination of these.
Prior Authorization is necessary for some medications to establish medical necessity, and to ensure eligibility for coverage per State regulations, Federal regulations, or both. This may be due to specific Food and Drug Administration (FDA) indications, the potential for misuse or overuse, safety limitations, or cost- benefit justifications.
A PA is required for certain medications that are:
- Outside the recommended age, dose, or gender limits;
- Not listed on the Preferred Drug List (PDL);
- Listed on the PDL but still require Prior Authorization;
- Brand name drugs when a generic exists;
- A Duplication in therapy (i.e. another drug currently used within the same class);
- New to the market and not yet reviewed by the P&T Committee;
- Prescribed for off-label use or outside of certain diseases or specialties; or
- Self-injectable and infusion medications (including chemotherapy) with some exceptions.
Providers may request an exception to Empower’s PDL either verbally or in writing. For written requests, providers should complete a Prior Authorization Request Form that includes pertinent enrollee medical history and information. Prior Authorization Request Forms may be accessed on Empower’s Pharmacy Forms and Resources page.
If authorization cannot be approved or denied, and the drug is medically necessary, up to a 72-hour emergency supply of the drug can be supplied to the member.