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Provider Manual

Office/Medical Setting Administered Medications that require prior authorization

Last Updated on December 31, 2019

Effective Nov. 1, 2017 Security Health Plan of Wisconsin, Inc. requires prior authorization (PA) and/or post-service claim edits (PSCE) for selected specialty pharmacy medications. Security Health Plan has partnered with Magellan Rx Management (Magellan Rx) to manage the review and approval of select specialty medications. To review a list of frequently asked questions about Magellan Rx,   click here.

For certain other specialty medications Security Health Plan will do PA/PSCE review and approval internal.

Please note: if a drug is denied due to the review processes outlined below any administration fee associated to that drug will also be denied.

Prior authorization list

Our ‘Medical pharmacy’ page identifies specialty medications that require PA and/or PSCE for dates of service on or after Nov. 1, 2017.

To view a full list of medications that require PA through Magellan Rx select ‘Magellan Rx Prior Authorizations’ from the Category drop down. To view a full list of medications that require PA directly through Security Health Plan select ‘Security Health Plan Prior Authorizations’ from the Category drop down. You may also search for a select medication by entering the drug code or generic/brand drug name in the ‘Search’ field. Medications that require PA through Magellan Rx will be indicated with ‘Prior authorization is required’ and under Contact Information will specify ‘To prior authorize, submit to Magellan Rx’. All Magellan Rx medications that require PA will also be subject to PSCE and is indicated with ‘Post service claim edits are applied’. See the ‘Post service claim edit’ section below for additional details on PSCE. Medications that require PA through Security Health Plan   will be indicated with ‘Prior authorization is required’ and under Contact Information will specify to log on to Security Health Plan’s provider portal or fax the completed Prior Authorization Request form to Security Health Plan.

To view prior authorization criteria or to submit an authorization to Magellan Rx click the ‘Submit a prior authorization’ link.

Submit a prior authorization

Post service claim edits

All Magellan Rx drugs that are subject to PA are also passed through PSCE checks. There are select drugs that do not require PA and are only subject to PSCE through Magellan Rx or Security Health Plan . Our ‘Medical pharmacy’ page identifies specialty medications that are subject to PSCE only by indicating ‘Post service claim edits are applied’ and does not indicate ‘Prior authorization is required’. The ‘Categories’ listed at the bottom of the drug will indicate whether PSCE is performed by Magellan Rx or Security Health Plan .

For more information on the Magellan Post Service Claim Edits Program and how it may affect your payment, click here. Magellan policies for PSCE can be found here.

PLEASE NOTE: For the following policies, Security Health Plan applies pre-payment, post-service claim edits using diagnosis and maximum unit criteria.

Pharmacy Utilization Management Guidelines

 

How does Security Health Plan decide which 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.

 

How does a member or provider request an exception for medical drug Step Therapy?

The process begins with communication between the prescriber, the member or the person appointed to manage the member’s care and Health Plan staff. 

The request must provide the following:

  • 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: 1-715-221-6616

    Call: Security Health Plan Health Services: 1-800-991-8109

    Written requests should be sent to:

    Security Health Plan
    Health Services Department
    PO Box 8000
    Marshfield, WI 54449-8000

  • For a “Standard” request, decision shall be granted or denied within 3 business days of receipt of the completed Step Therapy Override Determination form.

  • For an Urgent or “fast” request, an approval or denial will be granted by the end of the next business day after receipt of the complete Step Therapy Override Determination form

How does a member or provider appeal a denial for Step Therapy 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 a.m. to 5:30 p.m.    If you are hearing-or-speech-impaired   please call TTY: 711

To view the Step Therapy Override Determination Policy,  click here.