Pharmacy Authorization Process (Prior Authorization and Non-Formulary Medication Process)
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Defines MedStar Family Choice DC's process for evaluating and processing pharmacy prior authorization, non-formulary, urgent, and retrospective medication requests for Enrollees and providers.
Updated NCQA reference to 2025 version and added reference to DC PA Reform Amendment Act of 2023; clarified inclusion of DC regulations in policy statement.
Added maximum 6-month approval for controlled opioid medications and maximum 12-month approval for non-controlled and non-opioid controlled medications.
Added after-hours on-call process clarifying responsibilities of on-call Medical Reviewer and preauthorization staff.
Incorporated content from retired policy 212.DC and removed duplicative content; reorganized procedures to improve readability.
Coverage Criteria and Timelines
Decision criteria and timelines
Covered when a Medical Reviewer determines medical necessity and clinical appropriateness according to documentation and required criteria:
Includes urgent requests prioritized and processed no more than 24 hours from receipt.
Enrollee may initiate a retrospective request up to 180 days after the date of service (see related guidance). If approval occurs within 3 days of service instruct enrollee to return to the pharmacy for refund; approvals >=3 days require mailing receipts per Appendix I.
Medical Reviewer may use clinical judgment to issue partial approvals, shorten durations, or discontinue duplicate therapy; may request additional information when necessary.
Authorization duration — provider-requested with drug-specific maximums
Approval durations default to the provider-requested duration but are subject to drug-specific maximums and reviewer judgment:
Medical Reviewer may shorten durations or discontinue existing authorizations to avoid duplicate therapy; reviewer judgment applies to individual cases.
Prescriptions written by providers who are not in the plan network are covered only if there is not a reasonable equivalent in‑network provider of the same specialty. The Medical Reviewer will evaluate network provider status as part of the clinical review and may deny coverage when an appropriate in‑network alternative exists. Preauthorization staff and the Medical Reviewer may use provider outreach, the plan clinical software system, EMR data, PBM claims, and PDMP resources to confirm network availability and appropriateness.
For claim processing, submit all original pharmacy receipts. Cash register receipts will ONLY be accepted for diabetic supplies; for all other items the original pharmacy receipt is required. Receipts must include, at minimum, patient name, prescription number, medicine NDC number, date of fill, metric quantity, total charge, days supply, and pharmacy name/address or NABP number. Also include the prescribing physician's NPI and full provider contact information (name, address, city/state/zip, phone).
A Medical Reviewer (Medical Director or Health Plan Pharmacist) performs the clinical evaluation and makes the decision to approve, deny, or otherwise action any request based on documented medical necessity and clinical appropriateness. The reviewer will collate and summarize available clinical documentation and may obtain additional information as needed (provider outreach, EMR, lab data, PBM claims, PDMP) to support the determination.
Decisions follow the timelines in Table 1 and the procedures in this policy; when full information is not available the Medical Reviewer will evaluate available evidence to make a final determination. Denials will be issued in writing and include specific reasons, reference to the applicable guideline or benefit provision, applicable formulary alternatives, appeal instructions, and the name and credentials of the Medical Reviewer. Submissions that contain materially false, deceptive, incomplete, or misleading information may result in denial and potential civil or criminal penalties.
Policy Codes and Identifiers
| 202-243-6258 | Policy phone/fax number referenced for submissions (fax number listed separately in text) |
| NDC | Medicine NDC Number (required on receipt) |
| NPI | Prescribing Physician's NPI required |
| NABP | Pharmacy NABP Number (acceptable identifier) |
Provider Submission, Documentation, and Notifications
Who may submit PA, how to submit, and intake workflow
Prior authorization (PA) requests may be initiated by the prescriber, the Enrollee, or dispensing pharmacy staff and may be submitted by telephone, fax, or via the MedStar Family Choice DC website. Preauthorization staff will enter all requests into the clinical software system, categorize the request, document formulary status, and forward the request to a Medical Reviewer for evaluation. After‑hours requests are received by on‑call preauthorization staff who enter the request and send it to the on‑call Medical Reviewer; preauthorization staff process the Medical Reviewer’s decisions and place any needed PBM overrides and communicate the decision to the requester, Enrollee, and/or pharmacy.
- Acceptable submission methods: telephone, fax (fax number 202-243-6258), or MedStar Family Choice DC website/forms.
- Forms available: Pharmacy PA/Non‑Formulary form and Opioid PA form (links on pharmacy webpage).
- For phone requests preauthorization staff record date/time, Enrollee name, Enrollee telephone, prescriber name, and medication details.
- After‑hours: on‑call Medical Reviewer evaluates requests; on‑call preauthorization staff receive and enter requests and implement reviewer decisions.
Additional prior authorization operational notes
Operational details not specified in the provided source chunks.
Convert redirected requests to the formulary alternative
If the Medical Reviewer redirects a request to a formulary alternative and that alternative requires prior authorization or step therapy, the initial request may be converted to a request for the redirected medication and preauthorization staff may update the request accordingly.
- Redirects or voiding of requests require agreement by the original requestor when deemed appropriate by the Medical Reviewer.
- Preauthorization staff will update the request to the redirected medication when the Medical Reviewer successfully redirects it.
Step therapy handling
Step therapy procedures are not specified in the provided chunks.
Include clinical documentation; preauth staff will collate and obtain missing information
All PA requests must include clinical documentation demonstrating medical necessity; preauthorization staff will collate and summarize available clinical documentation and may obtain additional information via provider outreach, the plan’s clinical software, EMR, LabCorp data, PBM claims, or PDMP (CRISP‑DC).
- Preauthorization staff will collate and summarize supporting clinical documentation before forwarding to the Medical Reviewer.
- If additional information is needed the Medical Reviewer may request preauthorization staff to procure it (direct provider outreach, EMR, lab data, PBM claims, PDMP).
Attach original pharmacy receipts with required fields
For claims and retrospective submissions you must include all original pharmacy receipts (cash register receipts accepted only for diabetic supplies); receipts must contain patient name, prescription number, medicine NDC, date of fill, metric quantity, total charge, days’ supply, and pharmacy name/address or NABP number.
- Original pharmacy receipts are required for processing; cash register receipts accepted ONLY for diabetic supplies.
- Required receipt fields: Patient Name; Prescription Number; Medicine NDC Number; Date of Fill; Metric Quantity; Total Charge; Days Supply; Pharmacy Name and Address or NABP Number.
- Completed forms and receipts should be mailed to CVS Caremark P.O. Box 52136 Phoenix, Arizona 85072-2136 when submitting paper claims.
Include prescribing physician NPI and full contact information
Provide the prescribing physician’s NPI and full provider information (name, address, city/state/zip, and phone) as part of the submission.
- Include a valid Prescribing Physician NPI.
- Provide all prescribing physician fields: Name; Address; City, state, zip; Phone.
Pharmacist/representative and participant signatures required
Signatures are required: the pharmacist or authorized representative must sign the form, and the plan participant must sign and date to certify receipt and truthfulness of the information.
- Signature of Pharmacist or Representative is REQUIRED on the pharmacy information section.
- Signature of Plan Participant is REQUIRED, with date, certifying receipt and that information is true and correct.
Written denial must state reasons, references, alternatives, and appeal info
Denials will be provided in writing and must include the specific reason(s) for the denial in understandable language, a reference to the guideline or benefit provision used, formulary alternatives, directions to access the Formulary/PA & ST Table, appeal procedures and timelines, the name and credentials of the Medical Reviewer, and the option to discuss the denial with the Medical Reviewer.
- Denial letters must include: specific reason(s); reference to benefit provision/guideline; formulary alternatives; how to access Formulary/PA & ST Table; appeal initiation procedure; Medical Reviewer name/credentials; option to discuss denial; process and timeline for appeals; any additional information needed for appeal.
False or misleading information can lead to denial and legal penalties
Submitting claims or forms that contain materially false, deceptive, incomplete, or misleading information may result in denial of benefits and may subject the submitter to civil or criminal penalties including fines or imprisonment.
- The notice advises that knowingly fraudulent submissions may be a crime and may result in fines, denial of benefits, and/or imprisonment.
- Participant certifies that information provided is true and correct by signing the form.
Key Definitions
Policy Background and Scope
This procedure governs administrative clinical review of pharmacy requests to determine medication medical necessity and clinical appropriateness. Preauthorization staff collate and summarize clinical documentation and forward requests to a Medical Reviewer for evaluation. The Medical Reviewer considers medication adherence, network provider status, and any additional clinical evidence available through outreach and data sources when making determinations, and may set or limit approval durations based on drug‑specific rules and clinical judgment.
Step Therapy Handling
| Original Request Action | Conversion Rule | Who updates request | Notes |
|---|---|---|---|
| Initial request is redirected to formulary-preferred alternative | If the redirected formulary alternative requires prior authorization (PA) or step therapy (ST), the initial request may be converted to a request for the redirected medication | Preauthorization staff may update the request when the Medical Reviewer has successfully redirected the request | Redirect or void actions require agreement of the original requestor; Medical Reviewer must deem redirection appropriate |
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