Currentsierra health and lifePolicy N/A

Pharmacy Services — Prior Authorization, Step Therapy, and Drug Utilization Review

Governance of Sierra Health and Life (SHL) Pharmacy Services including prior authorization, exception requests, formulary management, call center operations, drug utilization review, and member reimbursement procedures for commercial lines of business.

Policy Summary

Payersierra health and life

PolicyPharmacy Services — Prior Authorization, Step Therapy, and Drug Utilization Review

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a fully completed Pharmacy Medical Necessity Request Form with supporting clinical information when requesting prior authorization or an exception.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

72 hoursroutine prior authorization goal turnaround time

24 hoursexpedited prior authorization goal turnaround time

12 monthsnew-to-market exclusion period

concurrent DURreal-time review

retrospective DUR

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Coverage Criteria

For SHL Commercial plans, new-to-market products may be excluded from review or coverage decisions for up to 12 months from their market introduction. This exclusion period is used to allow additional safety and clinical data to become available before the drug is considered for Preferred List inclusion or exclusion.

No additional coverage-exclusion entries are listed in this section.

Provider Submission, Authorization & Point-of-Sale Rules

Prior Authorization

Prior Authorization & Medical Necessity Form

Prior Authorization Required: A prior authorization is required when a drug is non‑formulary, is subject to protocol guidance, exceeds quantity limits, or when system edits indicate authorization is needed. Providers must submit a completed Pharmacy Medical Necessity Request Form with case‑specific clinical information (chart notes, labs, clinical rationale) to support the request. The form is available at www.sierrahealthandlife.com/provider/pharmacy-benefits and must be fully completed.

Triggers: non‑formulary drugs, protocol‑guided medications, quantity/limit exceedances, or other system edit triggers that prompt PA/step therapy alerts.
Required submission: Pharmacy Medical Necessity Request Form — fully completed with supporting clinical documentation.

Note

How to Submit Prior Authorization/Exception Requests

Submission methods: Online via the Online Provider Center (RX Prior Authorizations), fax to (702) 242‑6751 or 1‑(800) 997‑9672 (Mon–Fri, 8:00 a.m.–5:00 p.m.), or mail to: Pharmacy Services, Attn: Medical Necessity, P.O. Box 15645, Las Vegas, NV 89114‑5645. For assistance or status inquiries, contact Pharmacy Services at 702‑242‑7050 ext. 6‑1 or 1‑800‑443‑8197 ext. 6‑1 (Mon–Fri, 8:00 a.m.–5:00 p.m.).

Prior Authorization

Prior Authorization Turnaround Times

Turnaround times: Routine (standard) prior authorization requests are normally reviewed and a determination rendered within 72 hours. Expedited (urgent) requests — for services that could become an emergency without treatment — are normally reviewed and a determination rendered within 24 hours. If additional clinical information is required, the provider will be contacted (typically by fax) to supply the needed information; timely receipt of required documentation is necessary to meet these timeframes.

Routine requests: determination within 72 hours.
Expedited requests: determination within 24 hours.
Providers will be contacted if additional clinical information is needed; completion of submissions affects turnaround.

Step Therapy

Step Therapy & Point‑of‑Sale Enforcement

Step therapy & Point‑of‑Sale Enforcement: SHL enforces step therapy requirements via system edits at the point of sale. Pharmacy management system edits will generate alerts when initial steps of a therapy protocol have not been met; these edits may prevent dispensing until required prior steps are met or an approved exception/PA is on file. Medications that trigger step therapy or PA alerts at dispensing must meet the plan’s step therapy requirements or have an approved authorization before the prescription can be dispensed.

Point‑of‑sale enforcement: dispensing may be blocked until step therapy steps are satisfied or PA/exception is approved.
System alerts: notify pharmacists when medications require initial step completion or PA prior to dispensing.

Note

Concurrent and Retrospective Drug Utilization Review (DUR)

Concurrent and Retrospective DUR: SHL’s pharmacy management system performs concurrent drug utilization review at the point of sale to identify needs for prior authorization, step therapy, duplicate therapy, drug‑drug interactions, age/gender contraindications, incorrect dosing, misuse/overutilization, or underutilization. Retrospective DUR is performed after dispensing to identify population‑level medication management issues (e.g., interactions, overuse/abuse, duplicate therapy). Following retrospective DUR analysis, SHL may send letters to affected members, prescribing physicians, and pharmacists to educate and recommend changes.

Concurrent DUR: real‑time system edits and alerts prior to dispensing.
Retrospective DUR: periodic reviews; interventions may include letters to members, prescribers, and pharmacists.

Definitions — DUR Types and System Edits

Concurrent DUR (definition and actions)

DefinitionConcurrent DUR = real-time pharmacy management system edits and alerts prior to dispensing that identify needs for prior authorization, step therapy, drug–drug interactions, duplicate therapy, gender/age contraindications, incorrect dosing, misuse/abuse, overutilization, and underutilization.

Point of actionOperates at point-of-sale to prevent dispensing when system edits detect requirements not met (e.g., prior authorization or initial step therapy).

Alerts to pharmacistsProvides warnings and messages to pharmacists for potential clinical or administrative issues before a prescription is dispensed.

ScopeCovers contraindications, interactions, duplicate therapy, dosing errors, misuse/abuse, over- and underutilization as part of screening prior to each prescription being dispensed.

Retrospective DUR (definition and use)

Step Therapy Rules and Exception Process

Requirement	What the provider must submit
Clinical justification on Pharmacy Medical Necessity Request Form is required when requesting an exception or prior authorization
A fully completed Pharmacy Medical Necessity Request Form including pertinent case‑specific clinical information (chart notes, lab reports, clinical rationale); form available at www.sierrahealthandlife.com/provider/pharmacy-benefits

System behavior	Operational effect at point of sale
Pharmacy management system edits provide alerts and warning messages when ordered medications may need prior authorization or must meet initial step therapy requirements
Dispensing can be prevented or delayed at the point of sale until initial step therapy requirements are met or prior authorization/exception is granted

Quantity Limits and Monitoring

Quantity limits (policy-level thresholds)

When appliedQuantity limits may be instituted when plan quantity limits are exceeded or when continued high usage lacks supporting clinical data.

Policy authoritySHL may institute quantity limits on medications if there is no data to support continued high usage of the prescribed quantity/dosage.

Relation to prior authorizationRequests that exceed plan quantity limits may trigger prior authorization requirements as part of the screening process.

MonitoringHigh usage is monitored and may prompt policy-level actions (limits or prior authorization) when supporting data are absent.

Background

This document does not provide clinical disease background. Instead, it focuses on administrative and operational pharmacy services: real‑time concurrent drug utilization review at point-of-sale, system edits and alerts for prior authorization and step therapy, and other pharmacist-facing checks (duplicate therapy, interactions, contraindications, dosing errors, misuse/abuse, and utilization monitoring) that support formulary and dispensing controls.