Benefits

Prior authorization for prescription drugs: what participants need to know

Prescription medications sometimes need prior authorization (PA) to determine if the HealthSelectSM Prescription Drug Program (PDP), administered by OptumRx, can cover them.

Some medications must be reviewed because they may:

  • only be approved to treat specific conditions or
  • cost more than other medications used to treat similar conditions.

The PA review process happens between the doctor and OptumRx. If a medication requires a PA, the participant’s doctor must tell OptumRx why they need to take the medication so OptumRx can determine if the medication is covered under their PDP benefit. After OptumRx reviews the information from the doctor, OptumRx will send a letter to the participant and their doctor to confirm or deny coverage.

How to find out if a medication needs a PA

Participants can find out if their medication needs a PA in one of the following ways:

  • At the pharmacy: When they go to their preferred pharmacy to fill a new prescription, the pharmacist will tell them if a PA is required.
  • In the mail: If a PA is a new requirement for a medication, OptumRx will send the participant a letter.
  • Online: Participants can visit www.healthselectrx.com to see if their medication needs a PA. Click on the “Drug Pricing Tool,” then enter the prescription drug name and dose.
  • On the phone: Call OptumRx toll-free at (855) 828-9834 (TTY: 711).

If they have any questions about the prior authorization process and next steps, check out “Prior Authorization 101” under the Education Resources tab on www.healthselectrx.com or call an OptumRx customer care representative at (855) 828-9834 (TTY: 711).

Source: ERS Update Express (November 2020)

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