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Provider Manual

Medical pharmacy prior authorization

Last Updated on January 24, 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

The ‘List of medications that require prior authorization and post service claim edits  contains the list of Healthcare Common Procedure Codes (HCPCS) that require prior authorization (PA) for dates of service on or after Nov. 1, 2017. All Magellan Rx medications that require prior authorization will also be subject to post-service claim edits (PSCE). This is indicated by the presence of an ‘X’ in both the “PA required” and “PSCE required” fields. See the ‘Post service claim edit’ section below for additional details on post-service claim edits.

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. The ‘List of medications that require prior authorization and post service claim edits    specifies drugs that only require PSCE by indicating a ‘X’ under the “PSCE required” column and not under the “PA required” column.

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 at  here.

PLEASE NOTE: For the following policies, Security Health Plan applies pre-payment, post-service claim edits using diagnosis and maximum unit criteria. Prior authorization criteria do not apply for these policies.

List of medications that require prior authorization and post service claim edits.

How to use the ‘List of medications that require prior authorization and post service claim edits’ spreadsheet:

  • Column A – HCPCS: indicates the HCPCS code for the drug described in column B and C
  • Column B – Brand Name: indicates the Brand Name of the drug
  • Column C – Generic Name: indicates the Generic Name of the drug
  • Column D – PA required: indicates if the drug requires Prior Authorization (PA). If PA is required an ‘X’ will be present. If no ‘X’ is present than PA is not required.
  • Column E – PSCE required: indicates if the drug is subject to post-service claim editing (PSCE). If PSCE is done an ‘X’ will be present. If no ‘X” is present than PSCE is not done.
  • Column I – Prior Authorizations submitted to: indicates who manages PA or PSCE for the drug in column A. If MRX is present requests should be submitted to Magellan Rx. If SHP is present requests should be submitted directly to Security Health Plan.
  • Column J – Additional Information: supplies any other information related to the PA/PSCE such as past or future effective dates.