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Provider Manual

Prior Authorization - Medical Pharmacy

Last Updated on July 05, 2022

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

 

For certain other specialty medications Security Health Plan will complete prior authorization (PA) and/or post-service claim edits (PSCE) internally.

Prior authorization list

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.

 

Our ‘Medical pharmacy’ page identifies specialty medications that require PA and/or PSCE.

  • 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 prior authorization through Magellan Rx will be indicated with ‘Prior authorization is required’ and will specify ‘To prior authorize, submit to Magellan Rx’ under Contact Information. All Magellan Rx medications that require prior authorization will also be subject to PSCE as indicated with ‘Post service claim edits are applied’. See the ‘Post service claim edit’ section below for additional details.

 

Medications that require prior authorization through Security Health Plan will be indicated with ‘Prior authorization is required’ 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 prior authorization are also passed through Post Service Claim Edits (PSCE). There are select drugs that do not require prior authorization 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.