Baptist Health Plan and Pharmacy Prior Authorization Information
Due to the nature of some medications, prior authorization (PA) may be required for certain medications to be covered at any cost-sharing tier. This is outlined in your Baptist Health Plan (BHP) Certificate of Coverage (COC).
Why does my medication require Prior Authorization (PA)?
Medications that require PA do so because of their potential for misuse and/or abuse and will require that Plan criteria be met before approval is given. Claims exceeding $2,999.99 will reject for PA required. Experimental or investigational use of a medication is not covered, unless such use is consistent with standard medical practice and has been demonstrated as effective in published peer review medical literature.
What is STEP EDIT (SE)?
Step edit is an electronic PA process that takes place at the time the pharmacist files the claim. A step edit may include an age edit, a specialty prescriber edit, or a therapeutic alternative edit. If the step edit criterion is met, the system will approve the claim. If the step edit criterion is not met, the system will not approve the claim and will send a message back to the pharmacy advising that the step edit protocol has not been met. At that time, the pharmacy may contact your physician and request that they contact the plan for PA. If this does not happen, you will be responsible for contacting the physician to get the drug prior authorized. Step Edits for brand name medications also apply to generic alternatives.
Why are there are Quantity Limits (QL) for some prescriptions?
Quantity limits have been placed on medications to be consistent with the maximum dosages that the Food and Drug Administration (FDA) has designated to be both safe and effective. Prescriptions for which the quantity to be dispensed exceeds the FDA’s maximum daily dose are excluded. Quantity Limits for brand name medications also apply to generic alternatives.
How to obtain a Prior Authorization?
If a medication requires PA, your physician must contact BHP’s Pharmacy Services Department by phone 877.205.6308 or by fax 859.335.3744 to obtain an approval PRIOR to you receiving your medication. PA’s will NOT be issued after the prescription has been filled.
Prior Authorization Criteria and Request Forms
For your convenience, below is a list of medications that require a PA. Your physician will need to complete the appropriate form and fax to BHP’s Pharmacy Services Department at 859.335.3744.Prior Authorization Drug List