Drug Prior Authorization Program

General

Arise Health Plan’s drug prior authorization program supports evidence-based treatment and is intended to optimize the care provided by practitioners to our members.  Drugs subject to prior authorization may have specific safety issues, may require a higher level of care coordination, may compete with other products that offer similar or greater value, or may require specific testing to identify appropriate patients.  The prior authorization process gathers information so that a coverage decision can be rendered.

Requests for specialty Drugs are reviewed by our partner, Diplomat.  Non-specialty drugs that require review are either reviewed by our Pharmacy Benefit Manager, or, in rare instances, Arise.

  • To view the list of drugs that require prior authorization, who performs the review, and how to contact them click here.

Additional Information Concerning Specialty Drugs...

As noted above, Arise Health Plan has engaged Diplomat to assist with specialty drug management. Diplomat will review each treatment plan relative to evidence-based guidelines that may include step-therapy protocols.  Diplomat will ensure the specialty drug is provided in the most appropriate, cost-effective setting.  This includes self-administration or the home setting depending on the situation. Specialty drugs dispensed without proper authorization will not be reimbursed, and the member can be balance billed.

A provider can initiate a specialty drug authorization by calling Diplomat at 1-888-515-1357.

  • To view coverage policies for specialty drugs, click here.