Drug Formulary

Prior Authorization

Most health plan Drug Formularies have procedures to limit or restrict certain drugs. This is done to encourage doctors and patients to use these drugs appropriately, for the safety and best interest of all members. Most often, these drugs have safety issues, a high potential for inappropriate use, or have lower-priced alternatives on the formulary.

These drugs must meet specific criteria for use before they will be considered a covered benefit. During the pre-authorization process, your doctor will obtain approval from Arise Health Plan for you to receive coverage for a drug on the formulary. The process usually involves these steps:

1) Your practitioner may be required to send us certain medical information to help us make a decision.

2) Your practitioner’s office and you are notified as to whether or not the drug is approved.

3) If approved, the drug is prescribed to you.

4) If a drug pre-authorization has been denied, or not submitted, your pharmacy will not be able to file the drug claim under your prescription benefit, so you will be responsible for the entire cost of the prescription.

If a member would like to initiate the pre-authorization process with their provider, he/she may print this form and give it to the provider.