CurrentMedStar Family Choice–MarylandPolicy 218

Pharmacy Authorization Process

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Governs how medication authorization requests are received, evaluated, decided, and communicated for members, prescribers, dispensing pharmacies, preauthorization staff, and Medical Reviewers.

Policy Summary

PayerMedStar Family Choice–Maryland

PolicyPharmacy Authorization Process

Policy CodePolicy 218

Change TypeRevision with material changes

Effective DateJul 1, 2026

Next Review DateNot specified

Key ActionSubmit medication authorization requests with clinical documentation supporting medical necessity.

SourceLink

POLICY UPDATE CHANGES

The maximum approval period for non-controlled medications was revised to 6 to 12 months.

A decision-extension process was added allowing a one-time extension of up to 14 calendar days under specified conditions.

A Wegovy medication prior authorization form was added to the available submission forms.

The procedure was clarified to require categorization of the request reason and documentation of supporting clinical information and outreach attempts.

The procedure was clarified to permit redirection to a formulary-preferred alternative only through a Medical Reviewer or under the Medical Reviewer's direction.

24 hoursDecision and notification timeframe for urgent and other non-retrospective requests

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CurrentMedStar Family Choice–MarylandPolicy 218

Pharmacy Authorization Process

Customize your policy alerts

Sign up for medstarfamilychoicemaryland Policy 218 alerts

Get alerted when Policy 218 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Governs how medication authorization requests are received, evaluated, decided, and communicated for members, prescribers, dispensing pharmacies, preauthorization staff, and Medical Reviewers.

Policy Summary

PayerMedStar Family Choice–Maryland

PolicyPharmacy Authorization Process

Policy CodePolicy 218

Change TypeRevision with material changes

Effective DateJul 1, 2026

Next Review DateNot specified

Key ActionSubmit medication authorization requests with clinical documentation supporting medical necessity.

SourceLink

POLICY UPDATE CHANGES

The maximum approval period for non-controlled medications was revised to 6 to 12 months.

A decision-extension process was added allowing a one-time extension of up to 14 calendar days under specified conditions.

A Wegovy medication prior authorization form was added to the available submission forms.

The procedure was clarified to require categorization of the request reason and documentation of supporting clinical information and outreach attempts.

The procedure was clarified to permit redirection to a formulary-preferred alternative only through a Medical Reviewer or under the Medical Reviewer's direction.

24 hoursDecision and notification timeframe for urgent and other non-retrospective requests

30 daysDecision and notification timeframe for retrospective requests

180 daysRetrospective request submission window

14 daysMaximum one-time decision extension

6 monthsMaximum approval period for controlled medications

6–12 monthsMaximum approval range for non-controlled medications

Pharmacy Authorization Criteria and Timing

Pharmacy authorization decision criteria

Medication authorization requests are evaluated using submitted clinical information, medical necessity, clinical appropriateness, formulary status, applicable prior authorization or step-therapy requirements, and the applicable request requirements.

ALL of the following

Request is submitted by the prescriber, member, or dispensing pharmacy staff through an accepted channel: telephone, fax, or the MedStar Family Choice website.
Clinical documentation supporting medical necessity is provided or obtained.
The request identifies the reason for review, formulary status, whether the product appears on the High Cost Medications list, the prescriber's network status, and a summary of supporting clinical documentation.
A Medical Reviewer evaluates the request for medical necessity and clinical appropriateness.
ONE of
- Request is approved for the requested duration or a clinically appropriate shorter or partial duration.
- Request is redirected by the Medical Reviewer to a formulary alternative, including an alternative requiring prior authorization or step therapy.
- Request is denied, withdrawn, or otherwise acted upon with the required notification and appeal information.

Authorization duration and timing requirements

Approved requests and notifications must comply with drug-specific approval limits and applicable urgent, standard, retrospective, and decision-extension timeframes.

ALL of the following

Urgent requests, including urgent concurrent requests, are prioritized and the decision is communicated within no more than 24 hours of receipt.within 24 hours of receipt
All other non-retrospective or post-service pharmacy requests are decided and notified within 24 hours of receipt, unless an applicable decision extension is granted.within 24 hours of receipt
A one-time extension of up to 14 calendar days may be granted when requested by the member or when additional information is needed and at least one attempt to obtain it has been documented.
Retrospective or post-service requests are decided and notified within 30 calendar days of receipt.within 30 calendar days of receipt

Authorization Limits and Decision Timeframes

Controlled medication approval

Maximum approval period6 months

Applies toControlled medications

Shorter durationMay apply when identified on the PA and ST table or determined clinically appropriate

Non-controlled medication approval

Maximum approval period6 to 12 months

Applies toNon-controlled medications

Shorter durationMay apply when identified on the PA and ST table or determined clinically appropriate

Request Submission, Review, and Disposition

Prior Authorization

Submit an authorization request

Initiate a medication authorization request by telephone, fax, or the MedStar Family Choice website using the applicable submission form.

Available forms include the General Medication, Hepatitis C Medication, Opioid, and Wegovy Prior Authorization forms.

Documentation Required

Provide medical-necessity documentation

Include clinical documentation supporting medical necessity with the authorization request. Missing or insufficient clinical information may require additional outreach before a decision can be made.

Documentation Required

Key Pharmacy Authorization Terms

Request

DefinitionA request for coverage of a specific pharmaceutical product

RequestorsA member, prescriber, or dispensing pharmacy staff

Included requestsConcurrent and pre-service requests as defined by NCQA 2026 standards

Urgent Request

DefinitionA pharmaceutical-services request requiring expedited handling because the routine or non-life-threatening determination timeframe could seriously jeopardize the member's or another person's life, health, or safety

Practitioner assessmentA knowledgeable practitioner determines that the timeframe could cause adverse health consequences without the requested care or treatment

Policy Summary

PayerMedStar Family Choice–Maryland

PolicyPharmacy Authorization Process

Policy CodePolicy 218

Change TypeRevision with material changes

Effective DateJul 1, 2026

Next Review DateNot specified

Key ActionSubmit medication authorization requests with clinical documentation supporting medical necessity.

SourceLink

On This Page

Approval duration does not exceed six months for controlled medications or six to twelve months for non-controlled medications.controlled: maximum 6 months; non-controlled: maximum 6–12 months

A shorter period may apply under the PA and step-therapy table, for an initial versus renewal authorization, or when clinically appropriate in the Medical Reviewer's judgment.

Decision extension

Maximum extensionOne-time extension of up to 14 calendar days

May be requested byThe member

Additional-information conditionThe organization documents at least one attempt to obtain necessary information and the Medical Reviewer determines the information is insufficient to render a decision

Retrospective request window

Submission windowUp to 180 calendar days after the date of service

Who may initiateMembers

PurposeRetrospective coverage request, including applicable reimbursement processing

Standard pharmacy request timeline

Decision timeframeWithin 24 hours of the receipt date of the request for authorization

Applies toAll requests other than retrospective or post-service requests, including non-urgent preservice and urgent requests

Notification methodsTelephone or another telecommunication device; electronic or written notice is required for denials

Retrospective or post-service timeline

Decision timeframeWithin 30 calendar days of the receipt date of the request

Notification timeframeElectronic or written notification within 30 calendar days of the initial receipt date

Requests coveredRetrospective or post-service pharmacy requests

Supply complete request information

Provide complete request information so the request can be categorized and reviewed, including the review reason, formulary status, High Cost Medications list status, prescriber network status, and a summary of supporting clinical documentation.

Identify the reason for the request, such as a non-formulary exception, prior authorization requirement, early refill or vacation request, or quantity-limit exception.
Collate and summarize the clinical documentation supporting the request.

Documentation Required

Respond to information requests

Respond to outreach from the Medical Reviewer or preauthorization staff when additional information is needed. All provider outreach attempts and requested information must be documented in the clinical software system.

Record the date and time of each outreach attempt.
Record the outreach method, contact details, recipient name, and information requested.

Denial Risk

Medical review and disposition

The Medical Reviewer evaluates medical necessity and clinical appropriateness and may approve, deny, redirect, withdraw, partially approve, or shorten the authorization period based on the available information and applicable drug-specific limits.

If full information is unavailable, the Medical Reviewer may evaluate the available information.
Approval periods may be shorter when identified in the PA and ST table or when clinically appropriate.

Step Therapy

Formulary redirection

A request redirected to a formulary-preferred alternative requiring prior authorization or step therapy may be converted to a request for the redirected medication only after the Medical Reviewer successfully redirects it. Preauthorization staff may update the request under the Medical Reviewer’s direction.

Billing Rule

Process an approval

For an approved request, enter an override in the Pharmacy Benefits Management claims system so the prescription adjudicates for the approved duration, then notify the dispensing pharmacy to reprocess the claim.

Communicate the approval to the requestor by telephone, fax, or electronic portal.

Denial Risk

Communicate a denial

Provide the member and prescriber a written denial notice stating the specific reason, applicable benefit provision or criterion, formulary alternatives when applicable, appeal instructions and timelines, Medical Reviewer name and credentials, and any additional information needed for appeal.

Include directions for accessing the Formulary or PA & ST Table when applicable.
Include the option to discuss the denial with the Medical Reviewer and the right to obtain the benefit provision, guideline, protocol, or other criterion supporting the denial.

Prior Authorization

Meet decision timelines

Prioritize clinically urgent requests and make and communicate the decision within no more than 24 hours of receipt. Retrospective or post-service requests must be decided and notified within 30 calendar days of receipt.

Non-retrospective pharmacy requests, including urgent requests, are processed and notified within 24 hours of receipt.
A one-time extension of up to 14 calendar days may be granted under the applicable conditions when additional information is needed.

Billing Rule

Handle retrospective requests

Members may initiate a retrospective coverage request within 180 calendar days after the date of service and must follow the applicable reimbursement instructions.

If approval occurs within three days of the date of service, the member is instructed to return to the pharmacy for a refund.
If approval occurs more than three days after the date of service, the member is instructed to mail pharmacy and cash-register receipts using the form and instructions in Appendix I.

Processing implicationThe request is handled as urgent rather than under the routine determination timeframe

Decision Extension

DefinitionA one-time extension of up to 14 calendar days

When availableWhen requested by the member or when the organization needs additional information and has documented at least one attempt to obtain it

Reviewer conditionThe Medical Reviewer determines that the information provided is insufficient to render a decision

Retrospective or Post-Service Request

DefinitionA request for coverage of pharmaceutical services received after the services have been provided

Member reimbursement exampleA member paid out of pocket for a prescription and is seeking reimbursement

Request timingThe request is received after pharmaceutical services have been provided

Medical Reviewer

DefinitionThe Medical Director or Health Plan Pharmacist

Primary roleEvaluates pharmacy authorization requests

Decision roleRenders or supports the authorization decision