Prior Authorization

We have a team of doctors and pharmacists who help us create tools so we can offer good benefits to our members. Some of the tools are listed and described below:

  • Prior Authorization: We require you to get approval from us for certain drugs. We call this Prior Authorization. You may need a drug that is not on the List of Drugs. To get this drug covered you will need to get approval.  If you don’t get approval, you may be asked to pay for the drug.
  • Age Limits: Some drugs require approval if your age does not meet what is advised by the Food and Drug Administration (FDA) or clinical recommendations.
  • Quantity Limits: Some drugs limit the number of pills for a specific number of days.
  • Step Therapy: Some drugs require a less expensive drug before “stepping up” to drugs that cost more.

You can ask Buckeye Health Plan – MyCare Ohio to make an exception to our coverage rules

Refer to the List of Drugs for the types of exceptions. A doctor’s note should be submitted with the Coverage Determination form filled out for formulary or utilization exceptions.

We must decide within 72 hours of getting the note and form from your doctor. You or your doctor can request an expedited (fast) exception if your health is in danger. If the request for the fast exception is allowed, we must tell you our decision within 24 hours of getting the note and form from your doctor.

* Please note – You cannot use this form for Medicare non-covered drugs: fertility drugs, drugs prescribed for weight loss, weight gain or hair growth, over the counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations).

If you have questions or need the most recent List of Drugs, call Member Services at 1-866-549-8289. Hours are from 8 a.m. to 8 p.m., Monday through Friday. On weekends and on holidays, you may be asked to leave a message. Your call will be returned within the next business day. TTY users call 711.

Last Updated: 09/30/2017
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