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Provider Manual

Medical pharmacy prior authorization

Last Updated on May 17, 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.