Prior Approvals and Authorizations
You will need approval before you get some medical procedures and for some medicines. Your primary care provider (PCP) will ask for prior approval from First Choice. To find out if a procedure needs prior approval, please call Member Services at 1-888-276-2020.
If you need prior approval, your doctor must complete a prior authorization form (PDF) and return it to First Choice. If the request is not approved, you will get a letter telling you why. If you disagree with the reason, you can file an appeal. See prior authorization criteria (PDF).
Some prescriptions must be approved before you can get them filled. If a medicine needs prior approval, your doctor must complete a prior authorization form. See our preferred drug list (PDF) for more information about covered medicines.
If the request is approved, a notice is sent to your doctor. You can then get your medicine.
If the request is denied, you will get a letter explaining why. If you don't agree with the denial, you can appeal the decision. To file an appeal, call Member Services at 1-888-276-2020.
Ask your doctor if your drug needs prior approval when your doctor gives you the prescription. Most medicines do not require approval.
Some medicines need prior approval. Members may get an emergency supply of medicine that will cover them for 72 hours while a prior authorization request is pending. A member is permitted one temporary supply per prescription number. Inhalers, diabetic test strip and supplies, and creams or lotions are exceptions to the supply limit because of how they are packaged. For those medicines, the member may receive the smallest package size available.
Generic medicine and supplies will be provided when available. Members may get a supply of certain medicines, that lasts 90 calendar days, to treat asthma, hypertension, diabetes, and high cholesterol. Call Member Services for complete information about covered medicines, the appeal process or a complete list of participating pharmacies.
For prior authorization and other pharmacy services questions, call Member Services at 1-888-276-2020. You can also call Member Services to suggest adding to or deleting a medicine in the First Choice Preferred Drug List.