Prior Authorization

Prior Authorization Information

Definition of a Medically Necessary Service:

a) Definition of a Medically Necessary Service: A service is Medically Necessary if a physician or other treating health Provider, exercising prudent clinical judgment, would provide or order the service for an Enrollee for the purpose of evaluating, diagnosing or treating illness, injury, disease, physical or mental health conditions, or their symptoms, and the provision of the service is in compliance with 1905(a) of the Act, 42 U.S.C. § 1396d(a), to correct or ameliorate defects and physical and mental illnesses and conditions discovered by the screening services, whether or not such services are covered under the State Plan. Medically Necessary services shall be:

i) No more restrictive than those used in the Medicaid program, including quantitative and non-quantitative treatment limits, as indicated in District statutes and regulations, the State Plan, and other District policy and procedures;

ii) Services and benefits that promote normal growth and development and prevent, diagnose, detect, treat, ameliorate the effects or a physical, mental, behavioral, genetic, or congenital condition, injury, or disability for CASSIP Enrollees;

iii) Provided in accordance with generally accepted standards of medical practice;

iv) Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for the Enrollee’s illness, injury, disease, or physical or behavioral health condition;

v) Not primarily for the convenience of the Enrollee or treating physician, or other treating healthcare Providers, and more cost effective than an alternative service or sequence of services, and at least as likely to produce equivalent therapeutic or diagnostic results with respect to the diagnosis or treatment of that Enrollee’s illness, injury, disease or physical or mental health condition; and Specific to the Enrollee and shall take into account available clinical evidence, as well as recommendations of the treating clinician and other clinical, educational, and social services professionals who treat or interact with the Enrollee.

Services That Do Not Require Prior Authorization

The following services DO NOT REQUIRE prior authorization when performed by an in-network provider. View the complete list.

• Applied Behavior Analysis (ABA) evaluations (treatment requires PA)
• Breast pumps
• CPAP supplies
• Dental – primary dental office visits
• Diapers – standard diapers
• Emergency services
• Incontinence supplies
• Laboratory services
• Nebulizer machines
• Orthotic devices dispensed in the Emergency Room such as canes and crutches
• Outpatient mental health services (psychiatric evaluation, substance abuse treatment, medication management, and therapy (individual, group, family services)
• Primary care office visits
• Psychology and Neuropsychology evaluations (up to 1 every 3 years)
• Radiology services (including x-rays, sonograms/ultrasounds, MRIs, CT and PET Scans)
• Specialty care physician office visits
• Well woman and obstetrical care (including oral contraceptives, contraceptive injections such as Depo-Provera, intrauterine devices such as Mirena or Copper)
• Vision services (ophthalmology, optometry) including eyeglasses (1 pair per 24 months)

Services Requiring Prior Authorization

The following services REQUIRE prior authorization when performed by an in-network provider. View the complete list.

• Admission or Transfer to subacute facilities:
  • Rehabilitation facilities
  • Skilled Nursing Facilities (SNF)
  • Psychiatric Residential Treatment Facilities (PRTF)
  • Intermediate Care Facilities for Individuals with Intellectual Disability (ICF-IID)
• Applied Behavior Analysis (ABA) therapy
• Disposable Medical Supplies (DMS)
• Durable Medical Equipment (DME)
• Elective Procedures and Surgeries
• Home Health Services:
  • Skilled Nursing Visits
  • Home Health Aide Services
  • Home-Based PT, OT, or ST
• Hemodialysis
• Inpatient Hospital Services
• Intensive Day Treatment/Partial Hospitalization/Day Rehabilitation Programs
• Medical Injectables & Infusions
• Out-of-Network Services - All
• Outpatient Rehabilitative Therapies:
  • Speech-Language Therapy (ST)
  • Physical Therapy (PT)
  • Occupational Therapy (OT)
• Personal Care Aide (PCA) Services
• Private-Duty Nursing (PDN) Services
• Respite Services
• Summer Program Benefit
• Surgical Procedures
• Tele nutrition services – more than 12 visits per rolling 12 months

Admission to hospitals for acute care requires concurrent review. The hospital needs to notify HSCSN within 24 hours of admission and subsequent clinicals by the next business day.

Out of Network services always require prior authorization. If a provider elects to refer an HSCSN enrollee to a non-participating (out-of-network) provider/specialist for any reason, prior authorization must be obtained from HSCSN before the HSCSN enrollee receives the services.

Pharmacy Services Prior Authorizations

HSCSN contracts with CVS/Caremark as our Pharmacy Benefit Manager (PBM). HSCSN delegates utilization management for pharmacy services to the CVS/Caremark Utilization Management Department. CVS/Caremark is responsible for reviewing prior authorization and formulary exception requests for medications dispensed from an outpatient pharmacy and making determinations of medical necessity.  HSCSN’s Office of Appeals and Grievances handles all enrollees, and provider appeals and grievances regarding pharmacy services.

Pharmacy Services Prior Authorization (PA) Requirements

Formulary medications that require prior authorization are indicated in the HSCSN Drug Formulary (see below). Medications that are not on the formulary can be requested as a Formulary Exception through the prior authorization process. Use of a non-formulary medication usually requires that there is no formulary alternative.

A prior authorization request should include the following clinical details for a complete review and decision:

• Diagnosis being treated with the medication
• Clinical rationale
• Medication history (medications previously used)
• Relevant diagnostic testing and laboratory studies

Download the Prior Authorization Request Form

Medical Necessity Criteria

To obtain the medical necessity criteria used for a specific medication, providers may contact Utilization Management at CVS/Caremark.

• Fax: (888) 255-7569
• Telephone: (877) 433-7643

Submission of Pharmacy Services Prior Authorization (PA) Requests

Requests for prior authorization of pharmacy services should be submitted to the CVS/Caremark Utilization Management (UM) Department using one of the following methods:

• Fax: (888) 836-0732
• Telephone: (877) 433-7643

Providers can use the options below for submitting Electronic Prior Authorizations for prescription medications to CVS/Caremark:

• Covermymeds
• SureScripts

Access ePA from within their EHR workflow, reducing manual steps.

Turn-Around Times:

• Standard/non-urgent requests are addressed within 72 hours
• Expedited/Urgent requests will be addressed within 24 hours

Emergency Fills

For medications that cannot be filled due to lack of prior authorization, HSCSN allows a seven (7) day interim (emergency) supply of the medication to be filled by the pharmacist using an emergency override.  The emergency fill period gives the prescriber time to submit a PA request for the medication or to prescribe an alternative medication that does not require PA.

HSCSN Drug Formulary

The HSCSN Drug Formulary is based on the CVS/Caremark Managed Medicaid Template which is developed and maintained by their National Pharmacy and Therapeutics (P&T) Committee. The P&T Committee is an external advisory body of clinical professionals from across the United States. The P&T Committee’s voting members include physicians, pharmacists, a pharmacoeconomist, and a medical ethicist, all of whom have a broad background of clinical and academic expertise regarding prescription drugs. HSCSN modifies the formulary based on local requirements and to meet the needs of our enrollees and is updated quarterly. Visit the HSCSN Drug Formulary.