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 CoverMyMeds 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.

Prescribers interested in CoverMyMeds services can visit the CoverMyMeds Provider Portal for information and free sign-up. For personalized support, contact CoverMyMeds Customer Support at (866) 452-5017 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 (800) 476-2691. 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 CoverMyMeds 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.

If you would like to check the status of your prior authorization, please call our member services team at (844) 636-7506.

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: (800) 476-2691

• 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.