PBM/Payer Prior Authorization Coverage Lists

the prior authorization coverage list is the provider vendor’s primary means of knowing whether a medication needs prior authorization pbm/payers should ensure that they are sending prior authorization coverage lists in their formulary files this maximizes the epa workflow and allows prior authorizations to be completed before the prescription arrives at the pharmacy when coverage restrictions exist for a medication (such as quantity limits, step therapy, etc ) and pbm/payers allow prior authorizations, the drug should be flagged in the pa coverage list and the corresponding specific coverage restriction list this ensures that the provider vendor system can trigger painititiationrequests when appropriate when applicable, the pbm/payer returns a coverage id for the patient in the eligibility response (271) this id must correspond to a prior authorization coverage list id found in the pbms active formulary this is an essential link to ensure formulary data can be made available to the prescriber during the prescription writing process the prescriber utilizes the formulary information during the prescription writing processed to determine if the specific drug they want to prescribe requires a prior authorization the locations of these ids are as follows coverage id = ref02 within the eligibility response loop 2110c when ref01 = “cli” and ref02 is not null in the formulary file, see the coverage list detail prior authorization formulary