CCA Formulary Listings
Prior Authorization Requirements and Process
For some drugs, you will need to get approval (“prior authorization”) from Commonwealth Care Alliance before we can agree to cover a drug for your patient. The requirement for getting approval in advance may also help to guide appropriate use of certain drugs. If you do not get this approval, your patient’s drug might not be covered by the plan.
These documents provide lists of drugs that require prior authorization:
Submit Prior Authorization Form Online
Submit a prior authorization request for prescription drug coverage determination online, or through mail or fax using the form below.
Medicare Part B vs. D Forms
Prior authorization is required to determine appropriate coverage under Medicare Part B or Part D.
To initiate a Medicare Part B vs. D coverage determination request, please use the following method:
Call Navitus MedicareRx Customer Care at 1-866-270-3877. The Customer Care Agent can complete the questions on Navitus’ internal Primary Billing Form and complete the Part B vs. Part D request, allowing for an immediate determination over the phone.
- Anti-Rejection Drugs, Immunosuppressants
- ESRD/Dialysis-Related Drugs
- Immune Globulins
- Infusion/Injectable Drugs
- Nebulized Medications
- Oral Anti-Emetic Drugs
- Oral Chemotherapy Agents
- TPN / IDPN / IPN
- Treprostinil (TYVASO)
Navitus Health Solutions will review your request and make a determination as to whether the request meets the requirements for approval. The decisions for standard requests are made no later than 72 hours from when we received the request. If waiting 72 hours could potentially jeopardize a patient’s health, providers can send an expedited request for the patient, in which case a decision will be issued within 24 hours. For all expedited requests, providers must include a statement that they confirm that this request should be escalated.
If the request is denied, patients or their provider have the right to appeal our decision.
CCA Redetermination Form
If your request for coverage for a prescription drug was denied, you have the right to ask for an appeal of our decision within 60 days of the Notice of Denial.
The Prescriber Portal allows providers to access claim status, member eligibility, and claim submission options.
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