A prior authorization is a requirement from your health plan to approve certain medications or treatments before they can be covered. It ensures that the prescribed medication is appropriate and cost-effective.

Medications may require prior authorization to ensure they are medically necessary, not overly expensive when alternatives exist, and prescribed according to your plan’s guidelines. This review is conducted by a clinical team who closely follow clinical programs and criteria for medications that are appropriate for Prior Authorization and guidelines by U.S. Food and Drug Administration (FDA).

You can determine if your medication requires prior authorization through these channels:

• Local Pharmacy: Your pharmacist can check the status for you.
• Healthcare Provider: Ask your doctor or prescribing provider directly.
• Letter Communication: Check for a notification from CerpassRx.
• Formulary Information: Review your plan’s drug formulary for prior authorization details.
• CerpassRx: Call us at (844) 636-7506 for assistance.

It is recommended that your healthcare provider submits the prior authorization request on your behalf.

Your healthcare provider can submit a prior authorization request via electronic submission (ePA), fax, or mail. Each method is outlined below:

1. Electronic Submission (ePA): CerpassRx has partnered with Surescripts to bring the power of ePA directly to prescribers and their staff—at no cost to you!  This collaboration provides access to all prescribers to an easy-to-use, efficient solution that eliminates the hassle of traditional PA processes, such as mail and fax.

Getting Started with ePA in 3 Simple Steps

• Register
  • Register on the Surescripts Prior Auth Portal, Surescripts Prior Auth Portal. Create your prescriber account using your NPI, or work on behalf of a prescriber with a delegate account.
• Sign In
  • Log in to the portal to access your worklist, view task history, and manage your account settings seamlessly.
• Start Your Prior Authorization
  • Verify your prescriber details to initiate prior authorizations at the time of prescribing.

Prescribers interested in Surescripts services can visit the Surescripts Provider Portal for information and free sign-up. For personalized support, contact Surescripts Customer Support at (866) 797-3239 and follow the prompts. For all other questions call CerpassRx at (844) 636-7506.

2. Fax: Send completed PA forms with supporting clinical documentation to (469) 592-6460. Here are some helpful tips for fax submissions:

• Include only one member and one prescription per request.
• Attach all relevant supporting clinical documentation.
• Double-check for missing information and accuracy before faxing.

3. Mail: Send completed PA forms with documentation to the following address:

CerpassRx 

5904 Stone Creek Drive, Suite 120

The Colony, Texas 75056

Traditional PAs can take several days, but electronic prior authorizations (ePA) through systems like SureScripts can reduce this to just a few hours.

Yes! Once a determination is made, approval or denial letters are sent to the pharmacy, member, and prescriber.

With PA Pulse by CerpassRx, you can stay informed every step of the way. This real-time tracking tool provides timely notifications about your prior authorization status, including when it’s approved or if any additional actions are needed.

You can choose how to receive updates—via email, phone, or text—making it easy to stay connected.

To get started, visit https://papulse.cerpassrx.com. Simply enter your name, date of birth, member ID, and either your relationship code or home ZIP code for instant access to your prior authorization details.

Stay in control and informed with PA Pulse!

PA Pulse is a real-time tracking tool from CerpassRx designed to simplify and streamline the prior authorization process for members. It provides up-to-date information on the status of your prior authorization requests and ensures you’re notified at every step, from submission to approval.

Here’s how PA Pulse can help:

• Stay Informed: Receive timely updates about your prior authorization status, including approvals, denials, or if further action is required.
• Choose Your Notifications: Decide how you want to receive updates—via email, phone, or text—for maximum convenience.
• Instant Access: View your prior authorization information anytime with just a few details like your name, date of birth, member ID, and ZIP code or relationship code.

To get started, visit PA Pulse. Stay connected, informed, and in control of your healthcare with PA Pulse!

No, the prior authorization must be approved first unless you choose to pay the full cost of the medication out of pocket.

Yes! If the case is urgent, your provider can request an expedited review by selecting “urgent status” when submitting the prior authorization.

Renewal frequency depends on the specific medication. Typically, prior authorization coverage lasts 12 months, but shorter durations may apply.

If your prior authorization request is denied, both members and prescribers have the right to appeal. While members can initiate an appeal, it is preferred that the prescribing healthcare provider handles the process, as clinical chart notes and supporting medical documentation are typically required. If the appeal is denied, prescribers may request an external review. Detailed instructions for requesting an independent review will be provided with the appeal denial notification. All appeals must be submitted in writing within 180 days of receiving the denial notice..

• How to Appeal:
  • Include all relevant clinical information, medical reports, or additional documentation to support your case.
  • Ensure you include the patient’s name, address, identification number, and the reason for the appeal.
  • Send your appeal via mail or fax:
  • Address: CerpassRx, 5904 Stone Creek Drive, Suite 120, The Colony, Texas 75056
  • Fax: (469) 592-6460

• Appeal Types:
  • Standard Appeal (15 days): A decision will be provided within 15 days.
  • Fast Appeal (48 hours): If the patient’s health is at risk, you can request an expedited review. Documentation indicating urgency will automatically grant a fast appeal.

To ensure your appeal is reviewed efficiently, include the following: 

• Patient’s full name, address, and identification number.
• A detailed explanation of the reason for the appeal.
• Supporting documentation such as medical reports, prescriber letters, or clinical information.

If you have more questions, our CerpassRx Member Services team is here to help! You can reach us at (844) 636-7506. We’re happy to assist with any inquiries about your prior authorization or pharmacy benefits.