Pharmacy Prior Authorization

Providers are responsible for obtaining prior authorization. Providers may not bill members for services that require prior authorization and the authorization was not obtained, resulting in denial of the claim.

Authorization is not a guarantee of payment. Other limitations or requirements may apply.

Providers may check to see if a medication requires prior authorization by entering the HCPCS code into our Prior Authorization Lookup Tool.

How to submit a request for prior authorization

Online:

  • Your Electronic Health Record (EHR) tool software
    Care teams can use their electronic health record (EHR) system to process electronic prior authorization requests before a prescription is sent to the pharmacy.
    During the prescribing process, you’re alerted that a prior authorization is required.

    1. You’ll receive a question set electronically from PerformRxSM.
    2. Complete the question set and submit to PerformRx for review.
    3. Once the review is completed, you’ll receive a status notification. If approved, you’ll notify the pharmacy that the prescription can be processed.

  • Care teams can also submit electronic prior authorization requests after the prescription has been processed and rejected at the pharmacy.
    1. You’re notified by the pharmacy that the medication requires prior authorization.
    2. Take action within your EHR to initiate the prior authorization request.
    3. You’ll receive a question set electronically from PerformRx.
    4. Complete the question set and submit to PerformRx for review.
    5. Once the review is completed, you’ll receive a status notification. If approved, you’ll notify the pharmacy that the prescription can be processed.

When submitting a prior authorization request through the CoverMyMeds or SureScripts portals, please use the member's Select Health ID number, not their State Medicaid/Health Connections ID number.


By phone: Call 1-866-610-2773
Fax: Fax to PerformRx at 1-866-610-2775

Note: Please provide as much relevant medication information as possible. This will increase the accuracy of your submission. Incomplete forms will not be processed.

Brand-name medications

To request prior authorization for brand-name medication when a generic is available, Select Health requires you to demonstrate that our member had an adverse reaction to a previously prescribed generic. You will also need to fill out a MedWatch adverse incident reporting form (PDF) and submit it to the U.S. Food and Drug Administration (FDA).

This requirement improves the safety of our members by ensuring that both Select Health and the FDA are notified of the adverse reaction. Please visit the FDA’s MedWatch page for more information and to complete submission of the form.

Download the MedWatch adverse incident reporting form (PDF) 

Specialty and non-specialty prior authorization

Forms

Criteria

Providers