Medical benefit drug prior authorization

Security Health Plan of Wisconsin, Inc., is partnering with Prime Therapeutics Management to manage the process for reviewing and approving certain medical benefit drugs.

What are medical benefit drugs?

Medical benefit drugs are administered by a healthcare provider in the provider’s office, clinic, hospital or by home infusion. These drugs are primarily administered by:

• Intravenous (IV) injection
• IV infusion
• Intramuscular (IM) injection
• Intravitreal (ocular) injection
• Intra-articular (joints) injection
• Intrathecal injections
• Limited subcutaneous injections required in an emergency for acute conditions, or
• Drugs required as part of a surgical or diagnostic procedure

How does this benefit me?

Through the Prime Therapeutics Management program, your prescriber will have access to discuss the treatment plan and current guidelines and other clinical considerations surrounding these treatments with a physician in the same specialty from Prime Therapeutics Management. This change will help us manage your medical benefit drug costs and keep your premiums as low as possible.

Do I need to request a prior authorization or will my doctor do that for me?

Security Health Plan covers home infusion administration, including certain drugs, supplies and nursing services from an in-network provider. If your provider is in-network for your plan, the provider will obtain authorization on your behalf.   If your provider is not affiliated with Security Health Plan, you are responsible for initiating and ensuring authorization is on file prior to receiving services. 

To request a prior authorization for payment, have your provider contact Security Health Plan   before    the medical benefit drug is provided. With the exception of emergency or urgent care services, Security Health Plan will not pay for a medical benefit drug that has already been provided by a non-network healthcare provider, unless otherwise stated in your plan's Schedule of Benefits. All of the following criteria for prior authorization must be met:

• The services are not available from any network healthcare provider
• The services are a covered benefit under the member’s coverage
• The services are medically necessary and appropriate

Does this mean my prescriptions won’t be covered?

There will be no change in your member benefits. You will continue to receive the same care and access to drugs that are currently available as part of your medical and pharmacy benefits. As with all services, they must be medically necessary to be considered a covered service.

Does Medicare Part B cover home infusion drugs?
Some home infusion drugs may require prior authorization.  Learn more about  drugs are covered under the   home infusion benefit .

How do I know if a medical benefit drug I am prescribed requires a prior authorization?
For a list of medical benefit drugs that require prior authorization, see below.

Drugs that require prior authorization

Drugs with an asterisk (*) are managed by Prime Therapeutics Management. You can contact Prime Therapeutics Management at (800) 424-8243 to initiate a prior authorization request or request a peer-to-peer review. For all other drugs contact Security Health Plan at (800) 472-2363  (TTY: 711).