Prior Authorizations - Jefferson Health Plans

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

Medicare Advantage Prior Authorizations

2024

SNP
HMO/PPO

2025

Premium (Special, Dual Pearl)
Core (Prime, Complete, Silver, Platinum, Flex Plus, Flex Pro)
Value (Giveback, Flex, Choice, Choice Plus)

Prior authorization requests may be submitted by the member or the provider; however, supporting clinical information is usually needed from the provider.

Providers can request prior authorizations via the Provider Portal

Providers can fax prior authorization requests to 1-866-371-3239

Members can request a prior authorization by calling Member Relations:

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

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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