HealthPlus requires step therapy or prior authorization for selected drug products. The Step Therapy/Prior Authorization Program reflects our commitment to working with primary care physicians and specialists to offer safe and effective medications to HealthPlus members while managing costs.
HealthPlus selects medications for this program based upon the following criteria:
- High cost drugs with more cost-effective alternatives available that are equally safe and effective
- Brand-name drugs with an FDA-approved generic equivalent
- Drugs targeted for clinical/safety issues or drugs indicated only for a select group of patients
The HealthPlus Pharmacy and Therapeutics Committee develops recommendations and criteria for this program. The Medical Affairs Committee and Board of Directors review recommendations for approval. Members may appeal pharmacy step therapy or prior authorization decisions through the standard HealthPlus appeals process.
Requesting Step Therapy or Prior Authorization
To prescribe a medication that requires step therapy or prior authorization, or to submit a request for the Exceptions Process, the provider must complete and fax the Pharmacy Prior Authorization Form to the appropriate HealthPlus Pharmacy Department:
- Flint: (810) 720-2757
- Saginaw: (989) 797-4181
If the patient presents a prescription to the pharmacy and prior authorization or an exception has not been obtained, the pharmacy should contact the prescribing physician and suggest preferred alternatives or instruct the physician to complete the Pharmacy Prior Authorization Form. For medications included in the specialty injectable program, the physician may initiate the request for medication through the specialty vendor, at which time the specialty vendor will contact HealthPlus.
A certified HealthPlus pharmacy technician will review and approve the request. If a more extensive review is required, the request is forwarded to a registered HealthPlus pharmacist for approval. If the request meets criteria for approval, the physician will be notified, via fax, of the approval.
A fax response (to all requests) will be sent within the applicable timeframe, with appropriate written notification of the determination based upon applicable requirements. Requests that are denied must first go through a formal review process.
Prior to a request being denied, the request is reviewed by the HealthPlus Pharmacy Operations staff (including a Pharmacist) and the Plan Medical Director. In the event that a request is denied, a formal denial letter with appropriate supporting documentation will be provided to the Physician, by the HealthPlus Pharmacy Department. A denial of prior authorization or exception requests may only be determined by the Medical Director or physician designee.
If you have questions related to Step Theraypy and Prior Authorization please contact Customer Service at: 1-800- 332-9161.
Providers may request copies of all documents and references by contacting the HealthPlus Pharmacy Department at (810) 230-2118 or at firstname.lastname@example.org.