Pharmacy Utilization Management Guidelines

With the primary goal to ensure the safe and effective use of certain prescription drugs by our members, Security Health Plan uses processes known collectively as “utilization management.” These processes ensure that you receive the right drugs, all while helping to make medicine more affordable for you and everyone.

How does Security Health Plan decide which prescription and medical drugs require utilization management?

Security Health Plan’s Pharmacy and Therapeutics (P&T) Committee determines criteria to promote safe and effective use of drugs.

Policies are determined based on established clinical practice guidelines, clinical evidence, cost-effectiveness and the availability of alternatives to ensure safe, effective and proper use of drugs and health care dollars.  Clinical evidence may include peer-reviewed medical literature, accepted national treatment guidelines and opinions of clinical experts in various medical specialties.

What types of utilization management are administered by Security Health Plan?

Prior Authorization:

Security Health Plan has identified a list of medications for which prior authorization is required. The process includes requesting additional information from your provider. The prior authorization process may take up to 2 to 3 business days, not including the amount of time taken by the provider responding to the request.

Step Therapy:

In some cases, you may be required to try certain drugs before we will approve coverage for a different drug used to treat the same medical condition. This process is called step therapy.

Quantity Limits:

Quantity limits are designed to promote appropriate and efficient drug use, enhance patient safety and discourage misuse, waste and abuse.  Quantity limits are based on generally accepted pharmaceutical guidelines, FDA labeling, efficient dosing regimens and dosing recommendations.  Quantity limit drugs may be covered up to the amount indicated. 

Age limits help ensure patient safety. Some medications may require a prior authorization if your age does not meet the manufacturer, FDA, or clinical recommendations.

Formulary Exceptions:

A member may request a formulary exception (also called a medical exception) for a non-formulary prescription drug or medical supply.

How does a member or provider request an exception to prior authorization, step therapy, quantity limits or a formulary/medical exception?

The process begins with communication between the prescriber, the member or the person appointed to manage the member’s care, and Health Plan pharmacy staff.  The request may be initiated in writing or by verbal request.

The request must provide the following:

• Member name and date of birth
• Prescriber name, address, and telephone number
• Drug name, strength, dosage form, and directions
• Diagnosis
• Lab medical data
• Medical reason for request

• Information provided must be sufficient to assess whether the request meets criteria for approval.
• If the prescriber provides an oral supporting statement, the Health Plan may require the prescriber to subsequently provide a written supporting statement.
• The prescriber may also be required to provide additional supporting medical documentation as part of the written follow-up.
• The request and supporting documentation may be delivered via one of the following methods:
  • Fax: 715-221-9989
  • Email: shppharmacyum-mfld@Sanfordhealth.org
  • Call: Security Health Plan Pharmacy Services: 1-877-873-5611, Monday-Friday 8am-5pm
    • if you are hearing- or speech-impaired call TTY 711
  • Written requests should be sent to:
    • Security Health Plan
    • ATTN: Pharmacy Services
    • PO Box 8000
    • Marshfield, WI 54449-8000

• Notification of decision will be provided to the requesting provider by fax, member by mail, and the pharmacy by telephone or fax if the pharmacy information is included with the request.

How does a member or provider appeal a denial for Prior Authorization, Quantity Limit, Step Therapy or Formulary exception?

• If we deny your request, you can appeal our decision.
• A written appeal request should be sent to:

Security Health Plan
Attn:  Quality
PO Box 8000 
Marshfield, WI  54449-8000
Fax 715-221-9500

• When we give you our decision, we will use the “standard” deadlines unless we have agreed to use the “fast” deadlines. A standard appeal means we will give you an answer within 30 days of receiving your request.
• Remember, if your health requires it, ask us to give you a “fast appeal.” A fast coverage decision means we will give you an answer within 72 hours of receiving your request.
• To request a fast appeal, call 1-800-472-2363 or TTY 711.   We are open Monday through Friday, 7:00 a.m. to 5:00 p.m.    If you are hearing-or-speech-impaired   please call TTY 711.