CurrentMedStar Family Choice–MarylandPolicy 218

Pharmacy Authorization Process

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Governs how medication authorization requests for non-formulary or prior-authorization medications are received, evaluated, decided, and communicated.

Policy Summary

PayerMedStar Family Choice–Maryland

PolicyPharmacy Authorization Process

Policy CodePolicy 218

Change TypeAdministrative clarifications and reference updates

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionSubmit medication authorization requests by telephone, fax, or the MedStar Family Choice website with clinical documentation supporting medical necessity.

SourceLink

POLICY UPDATE CHANGES

Added a one-time decision extension of up to 14 calendar days when requested by the member or when additional information is needed and an attempt to obtain it is documented.

Added the Wegovy medication prior authorization form to the available submission forms.

Clarified that requests must be categorized by reason and that staff may use specified outreach and data sources to obtain supporting documentation.

Clarified that at least one attempt to obtain additional clinical information must occur within the first 24 hours after request receipt.

Updated regulatory and accreditation references to the 2025 NCQA and Maryland standards and current COMAR references.

24 hoursUrgent and non-retrospective decision timeframe

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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 for non-formulary or prior-authorization medications are received, evaluated, decided, and communicated.

Policy Summary

PayerMedStar Family Choice–Maryland

PolicyPharmacy Authorization Process

Policy CodePolicy 218

Change TypeAdministrative clarifications and reference updates

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionSubmit medication authorization requests by telephone, fax, or the MedStar Family Choice website with clinical documentation supporting medical necessity.

SourceLink

POLICY UPDATE CHANGES

Added a one-time decision extension of up to 14 calendar days when requested by the member or when additional information is needed and an attempt to obtain it is documented.

Added the Wegovy medication prior authorization form to the available submission forms.

Clarified that requests must be categorized by reason and that staff may use specified outreach and data sources to obtain supporting documentation.

Clarified that at least one attempt to obtain additional clinical information must occur within the first 24 hours after request receipt.

Updated regulatory and accreditation references to the 2025 NCQA and Maryland standards and current COMAR references.

24 hoursUrgent and non-retrospective decision timeframe

30 daysRetrospective decision timeframe

180 daysRetrospective filing limit

6 monthsControlled medication approval limit

12 monthsNon-controlled medication approval limit

14 daysDecision extension

Clinical Review and Authorization Outcomes

Clinical review and authorization outcomes

Medication authorization requests requiring clinical review are evaluated by a Medical Reviewer.

Clinical review

Evaluate the request for medical necessity and clinical appropriateness.
For non-formulary medication requests, determine medical necessity under Pharmacy Policy 205, Sections 6 and 7.
When complete information is not available, evaluate the available information to make a decision.
One applicable clinical review outcome
- Approve the request.
- Deny the request.
- Redirect the request to a formulary alternative; when the alternative requires prior authorization or step therapy, the initial request may be converted to a request for the redirected medication.
- Withdraw the request when the original requestor agrees.
- Partially approve the request or shorten the approval period when clinically appropriate.

Authorization administration and notification

Approval and denial processing must follow the applicable authorization, notification, and appeal requirements.

Authorization administration

Apply drug-specific, controlled-medication, non-controlled-medication, initial-authorization, renewal, and clinical-duration limits to the approval period.
The default approval period is the duration requested by the provider; controlled medications are limited to 6 months and non-controlled medications to 12 months.
For an approved request, enter an override in the Pharmacy Benefits Management claims system for the approved duration, direct the dispensing pharmacy to reprocess the claim, and communicate the approval to the requestor by phone, fax, or electronic portal.
For a denied request, provide written notice to the member and prescriber stating the specific denial reasons, the supporting benefit provision, guideline, protocol, or other criterion, applicable formulary alternatives, directions to access the Formulary or PA & ST Table when applicable, the Medical Reviewer’s name and credentials, the option to discuss the denial with the Medical Reviewer, the appeal process and timeline, and any additional information needed for the appeal.

Authorization Timeframes and Duration Limits

Controlled medication approval duration

Controlled medication maximum approval duration6 months

Default approval periodThe duration requested by the provider

Additional limitationThe approval period may be shorter based on drug-specific, initial-versus-renewal, or clinical limitations

Non-controlled medication approval duration

Non-controlled medication maximum approval duration12 months

Default approval periodThe duration requested by the provider

Additional limitation

Request Submission and Processing Responsibilities

Prior Authorization

Submit an Authorization Request

A medication authorization request may be initiated by the prescriber, member, or dispensing pharmacy staff by telephone, fax, or through the MedStar Family Choice website.

Submit by fax: 410-933-2274 or 410-350-7492.
Submit by phone: 410-933-2200 or 800-905-1722.
Use the corresponding submission form when submitting by telephone or fax. Forms are available at https://www.medstarfamilychoice.com/maryland-providers/pharmacy-prescriptioninformation.

Documentation Required

Provide Required Documentation

Include clinical documentation supporting medical necessity with the authorization request. Use the applicable medication prior authorization form available on the MedStar Family Choice pharmacy website.

Key Terms

Request

DefinitionA request for coverage of a specific pharmaceutical product

Who may make the requestA member, prescriber, or dispensing pharmacy staff

Included request typesConcurrent and pre-service requests

Urgent Request

DefinitionA pharmaceutical-services request for which using the routine or non-life-threatening determination timeframe could seriously jeopardize the member’s or others’ life, health, or safety

Practitioner standardA knowledgeable practitioner determines that the timeframe could subject the member to adverse health consequences without the requested care or treatment

Policy Summary

PayerMedStar Family Choice–Maryland

PolicyPharmacy Authorization Process

Policy CodePolicy 218

Change TypeAdministrative clarifications and reference updates

Effective DateJul 1, 2025

Next Review DateN/A

Key ActionSubmit medication authorization requests by telephone, fax, or the MedStar Family Choice website with clinical documentation supporting medical necessity.

SourceLink

On This Page

Provide any forms required for the appeal or approval process and, upon request, a copy of the actual benefit provision, guideline, protocol, or other criterion supporting the denial.

Process clinically urgent requests and provide notification of the decision no more than 24 hours from the date of receipt.

Process retrospective or post-service requests and provide a decision and notification within 30 calendar days of receipt.

Members may initiate a retrospective coverage request up to 180 calendar days after the date of service.

The approval period may be shorter based on drug-specific, initial-versus-renewal, or clinical limitations

Decision extension

Maximum extensionOne time, up to 14 calendar days

Member-requested extensionMay be granted when requested by the member

Additional informationMay be granted when the organization needs additional information and documents at least one attempt to obtain it, or when the Medical Reviewer determines the information is insufficient to render a decision

Urgent and non-retrospective requests

Decision and notification timeframeWithin 24 hours of receipt

Applicable requestsUrgent, non-urgent preservice, and urgent concurrent requests other than retrospective or post-service requests

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

Retrospective or post-service requests

Decision timeframeWithin 30 calendar days of receipt

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

Who is notifiedThe member or member’s representative and the treating physician, clinician, or requesting provider

Retrospective request filing limit

Filing limitUp to 180 calendar days after the date of service

Early approval reimbursementIf approved within 3 days of the date of service, the member is instructed to return to the pharmacy for a refund

Later approval reimbursementIf approved more than 3 days after the date of service, the member is instructed to submit pharmacy and cash register receipts using the required form and instructions

General Medication Prior Authorization form

Hepatitis C Medication Prior Authorization form

Opioid Prior Authorization form

Wegovy Prior Authorization form

Note

Provide Telephone-Request Information

For telephone requests, preauthorization staff will record the information needed to enter and evaluate the request. Be prepared to provide complete caller, member, prescriber, and requested-medication details.

Caller information, including the caller's name and telephone number.
Member's name and telephone number.
Prescriber's name.
Details about the medication being requested.

Note

Handle After-Hours Requests

Requests submitted outside normal business hours are handled through the on-call process. A preauthorization staff member receives the request, enters it into the clinical software system, and forwards it to an on-call Medical Reviewer for evaluation and decision.

Normal business hours: Monday through Friday, 8:30 a.m. to 5:00 p.m.
The on-call Medical Reviewer reviews after-hours pharmacy requests.
Preauthorization staff enter any needed PBM overrides and communicate the decision to the requestor, member, and/or pharmacy as needed.

Documentation Required

Prepare the Request for Clinical Review

Preauthorization staff enter every request into the clinical software system and prepare it for Medical Reviewer evaluation. The intake record must capture the request category, product and network information, supporting documentation, and a summary of the clinical information.

Categorize the request, such as a non-formulary exception, prior authorization requirement, early refill or vacation request, or quantity-limit exception.
Document the requested product's formulary status and whether it appears on the High Cost Medications list.
Collate and summarize clinical documentation supporting the request.
Document whether the prescriber is a network or non-network provider.
Forward the preliminary request to the Medical Reviewer.

Documentation Required

Support Information Requests

When additional information is needed, preauthorization staff may obtain it from available clinical and claims resources, and the Medical Reviewer may request information from the prescriber. At least one attempt to obtain needed clinical information must occur within the first 24 hours after receipt of the request.

Potential resources include direct provider outreach, the MedStar clinical software system, the MedStar system EMR, LabCorp data, and the PBM Claims reporting database.
Record every provider outreach attempt in the clinical software system.
Document the outreach date and timestamp, outreach type, contact details and recipient name, and the information requested.
The Medical Reviewer may ask preauthorization staff to obtain information or may contact the prescriber directly; CRISP may also be accessed, excluding the Prescription Drug Monitoring Portal (PDMP).

Note

Understand Clinical Review Outcomes

The Medical Reviewer evaluates requests for medical necessity and clinical appropriateness and may approve, deny, redirect, withdraw, or otherwise act on the request. Decisions may be based on the available information when the full record is not available.

For non-formulary requests, medical necessity is determined under Pharmacy Policy 205, Sections 6 and 7.
A request may be redirected or withdrawn if the original requestor agrees.
A request may receive a partial approval or a shorter approval duration when clinically appropriate.
Decision and notification timelines follow the applicable policy requirements; clinically urgent requests are prioritized and notified within no more than 24 hours of receipt.

Step Therapy

Process Formulary Redirection

When a Medical Reviewer successfully redirects a request to a formulary alternative that requires prior authorization or step therapy, the initial request may be converted to a request for the redirected medication.

Preauthorization staff may update the request after the Medical Reviewer successfully redirects it.
Formulary redirection or a determination that the request is withdrawn is processed within 24 hours of receipt.

Prior Authorization

Apply Approval-Duration Limits

The default approval period is the duration requested by the provider, subject to drug-specific and clinical limits. Approval periods may differ for initial and renewal authorizations and may be shortened by the Medical Reviewer when clinically appropriate.

Controlled medications: maximum 6-month approval.
Non-controlled medications: maximum 12-month approval.
The PA and ST table may specify a shorter duration.
Medical Reviewers may issue a partial approval or shorter duration based on clinical judgment.

Denial Risk

Avoid Duplicate Therapy

MedStar Family Choice reserves the right to discontinue an existing authorization when a new authorization would create duplication of therapy. This may occur when the prescriber has discontinued the previously authorized medication.

Review for duplicate therapy when submitting or processing a new authorization.
An existing authorization may be discontinued when the new authorization creates duplication of therapy.

Billing Rule

Process Approved Authorizations

For an approved request, preauthorization staff enter a PBM claims-system override so the prescription adjudicates for the approved duration. The dispensing pharmacy must reprocess the claim, and the approval is communicated to the requestor by phone, fax, or electronic portal.

Enter the required override in the Pharmacy Benefits Management (PBM) claims system.
Notify the dispensing pharmacy to reprocess the claim.
Communicate the approval to the requestor by phone, fax, or electronic portal.

Denial Risk

Communicate Denials

Notify the member and prescriber of a denial in writing. The denial notice must explain the decision, identify the supporting criteria and available alternatives, and provide the applicable discussion and appeal information.

State the specific denial reason(s) in easily understood language.
Reference the benefit provision, guideline, protocol, or other criterion supporting the decision.
List formulary alternatives, when applicable, and directions to access the Formulary and/or PA & ST Table.
Identify the Medical Reviewer by name and credentials and provide the option to discuss the denial with the Medical Reviewer.
Describe the appeal process and timeline, including any additional information needed for the appeal.
State that members may request a copy of the actual benefit provision, guideline, protocol, or other criterion supporting the denial.
Include any required forms, such as a MedWatch form when required for approval of a brand medication. Appeals are described in Policy 301: Member Appeals and Policy 307: Provider Appeals.

Billing Rule

Handle Retrospective Reimbursement

Members may initiate a retrospective coverage request up to 180 calendar days after the date of service. Reimbursement instructions depend on when the authorization is approved.

If approval occurs within 3 days of the date of service, instruct the member to return to the pharmacy for a refund.
If approval occurs more than 3 days after the date of service, instruct the member to mail pharmacy and cash-register receipts using the form and instructions in Appendix I.

Processing expectation

Urgent requests are prioritized and processed as expeditiously as feasible, not to exceed 24 hours from receipt

Decision Extension

DefinitionA one-time extension of up to 14 calendar days

When requested by the memberThe extension may be granted when the member requests it

When more information is neededThe extension may be granted when the organization documents at least one attempt to obtain necessary information or when the Medical Reviewer determines the information is insufficient to render a decision

Retrospective or Post-Service Request

DefinitionA request for coverage of pharmaceutical services received after the service

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

Request purposeCoverage review and reimbursement for services already received

Medical Reviewer

DefinitionA Medical Director or Health Plan Pharmacist

Review roleEvaluates available information to make a decision when full information is not available

Decision authorityMay redirect requests or withdraw them when the original requestor agrees