Prescription Drugs
Prior Authorizations

To be sure that certain medications are used appropriately, prior authorization (plan approval) may be required before prescriptions for these drugs can be filled.

Prior authorization may be required for the following drugs and reasons:

  • Non-formulary medications or benefit exceptions required by medical necessity
  • Prescriptions that exceed set plan limits (days’ supply, quantity, cost)
  • Certain brand name medications when there is an A-rated generic version available
  • New-to-market products
  • Medications and/or treatments if they are under clinical investigation
  • Medications that have treatment guidelines developed by the Jefferson Health Plans Pharmacy & Therapeutics Committee
  • Medications prescribed for non-FDA approved uses
Plan Prior Authorizations

2024

2025

  • Premium (Special, Dual Pearl)
  • Core (Prime, Complete, Silver, Platinum, Flex Plus, Flex Pro)
  • Value (Giveback, Flex, Choice, Choice Plus)
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Prior authorization requests may be submitted by the member or the provider; however, supporting clinical information is usually needed from the provider.

Call us to request prior authorization:

1-866-901-8000 (TTY 1-877-454-8477)

Requests can be faxed to:

1-866-371-3239

To initiate a prior authorization request, please visit our pharmacy portal. 

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Prescription Drugs
Still Have Questions?

If you need help or have questions about prior authorization, please call Member Relations at 1-866-901-8000 (TTY 1-877-454-8477).

From October 1 to March 31, we’re available 8 a.m. to 8 p.m., 7 days a week (closed on Thanksgiving and Christmas). And from April 1 to September 30, we’re available 8 a.m. to 8 p.m., Monday to Friday.

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Page last updated: 10/1/2024 - Y0170_MCE‐220S05‐4991_M