Providers and Pharmacists

Prior authorizations (PA) play an important role in maximizing the clinical benefit of pharmacy care, minimizing patient exposure to unnecessary health risk, and reducing waste.

How to submit an electronic prior authorization (ePA)

Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. The online process is faster and easier to complete, and the response is automatic, which helps patients get their medications sooner. You can complete this process through your current electronic health record/electronic medical record (EHR/EMR) system or via the following ePA sites:
 

• Surescripts®: providerportal.surescripts.net/providerportal
• CoverMyMeds®: www.covermymeds.com/main
• CenterX®: Submit through EPIC EMR.

Creating an account is free and takes just a few minutes. 
 

• For questions or issues with the Surescripts portal, call 866-797-3239.
• For questions or issues with the CoverMyMeds portal, call 866-452-5017.
• For questions or issues with the CenterX, please reach out to your EMR vendor. If you are experiencing technical difficulties with submitting an electronic prior authorization, call to submit a verbal prior authorization. Our prior authorization team is available from 8 a.m. – 9 p.m. ET Monday – Friday and Saturday from 10 a.m. to 2 p.m. ET. If you cannot submit requests to the CarelonRx prior authorization department through ePA or telephone.

If you have questions about our utilization management policies, obtaining copies of our clinical criteria, or if you need to speak to someone about a prior authorization/exception request, please call us at 833-293-0659 from 8 a.m. to 9 p.m. ET Monday – Friday and Saturday from 10 a.m. to 2 p.m. ET.

An independent group of practicing doctors, pharmacists and other healthcare professionals on the P&T Committee meets often to look at new and existing drugs. They choose drugs for our formulary based on several factors, including how well they work, value to patients, and safety. All drugs on our formulary are approved by the Food and Drug Administration (FDA).
 

By using a member’s formulary as an input to prescribing decisions, providers can maximize the clinical benefit of pharmacy care, avoid clinically inferior drugs, minimize patient exposure to unnecessary health risk, and reduce waste.
 

A list of recent updates to our drug lists can be found here.
 

If you have questions about the formulary of a specific member, you can access the Real Benefit Check tool in your electronic medical record (EMR) platform to view specific drug information.

Qualified licensed health professionals assess the clinical information submitted to support utilization management (UM) decisions. As the responsible organization for UM, CarelonRx affirms that decisions are based only on appropriateness of care and service and existence of coverage.
 

The organization does not specifically reward practitioners or other individuals for issuing denials of coverage. Financial incentives for UM decision makers do not encourage decisions that result in underutilization or create barriers to care and service.