Branching diagram

Request to initiate a PA

Once you have confirmed there is not an active approval on file, move forward with the following PA process.

A member, pharmacy, or MDO calls to initiate a prior authorization

Yes

No

Is the medication covered under the member's plan?

Since the medication is not covered, inform the caller of the exclusion and generate an exclusion lettter for the MDO

Yes

No

Inform the caller that the PA has expired and updated progress notes are required. Fax a PN request to the MDO.

Has this PA been approved previously?

Generate a PA Request form and fax it the MDO

Remeber to send the letter for review before faxing it to the MDO

Remeber to confirm you have an up-to-date fax number for the MDO

START

A member, pharmacy, or MDO calls to initiate a prior authorization. Make sure you check the CSL to see if there is an existing case for this medication/member. Once you have confirmed there is not an active approval on file, move forward with the following PA process.

Request to initiate a PA

Initiate a PA

Is the medication covered under the member's plan?

No

Yes

Since the medication is not covered, inform the caller of the exclusion and generate an exclusion lettter for the MDO. Remeber to send the letter for review before faxing it to the MDO

Has this PA beenapproved previously?

No

Yes

Inform the caller that the PA has expired and updated progress notes are required. Fax a PN request to the MDO. Remeber to confirm you have an up-to-date fax number for the MDO

Generate a PA Request form and fax it the MDO

Make sure you check the CSL to see if there is an existing case for this medication/member