PRIOR AUTHORIZATIONS

Prior Authorization Guidelines

Not all drugs are covered on the Marketplace plans. Each drug will be noted below if not covered. Please review the Marketplace formulary for an alternative medication. Not all medications listed will require a Prior Authorization on the Marketplace plans. Please check the Marketplace formulary listed on the website.

For certain prescription drugs, AultCare has additional requirements for coverage. These requirements ensure that the drug prescribed is clinically appropriate for the plan member and also helps us manage drug plan costs. A team of physicians and pharmacists developed these requirements for our plan to help us provide quality coverage to our members.

The requirements for coverage on certain drugs are listed as follows:

Prior Authorization: We require you to get a prior authorization (prior approval) for certain drugs. This means that authorized prescribers will need to get approval from us before you fill your prescription. If they don’t get approval, we may not cover the drug.

Step Therapy: In some cases, we require you to try one drug first before we will cover another drug for that medical condition. For example, if drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.

You can find out if the drug you take is subject to these additional requirements by looking on our web site or by calling customer service. If your drug is subject to one of these additional restrictions your physician must print and complete the corresponding enrollment form for the drug he/she is prescribing and fax it to AultCare at 330-363-3284. Coverage decisions are made on a case-by-case basis considering the individual member's health care needs.

*This list is subject to change



New Medications Added

Aimovig
Ajovy
Aliqopa_Fillable
Balcoltra_Fillable
Calquence_Fillable
Emgality
Erleada - Fillable_Fillable
Fasenra_Fillable
Flebogamma DIF
Gamunex-C-Gammaked
Imfinzi
Kymriah
Lutathera
Luxturna
Lyrica CR_Fillable
Radicava
Sandostatin Non-Depot
Sinuva
Symdeko_Fillable
Verzenio_Fillable
Xhance_Fillable
Yescarta