Principals/Vice-Principals (P/VP)

Prior Authorization

Prior authorization is a review process for specialty drugs (those that cost $5,000 or more per year and other categories, such as anti-obesity medications). Specialty drugs are used to treat certain conditions; here are a few examples: rheumatoid arthritis, Crohn’s disease, multiple sclerosis, obesity, and psoriasis.

These specialty drugs must go through a prior authorization process before they can be approved for coverage through the Plan. In many cases, when you are prescribed a specialty medication requiring prior authorization, you will be notified at the physician’s office. Your pharmacist may also advise if authorization is required.

Prior authorization of specialty drugs is done through FACET, a program operated by the ONE-T service partner Cubic Health. Here’s how the process works:

  • Specialty drug claims are reviewed by a clinical pharmacist at Cubic Health, someone who has no financial involvement in the claim, using a transparent, evidence-based protocol and set of clinical criteria by independent experts.
  • Member safety is a critical consideration in the decision-making process. The review focuses on two fundamental questions:
    • Based on all clinical information provided (and subsequently validated), does the member meet the established evidence-based criteria for any specialty drug for the specific disease state?
    • If so, is the medication prescribed the most appropriate first-line specialty product, at the most appropriate dose for this member?

The goal is to make sure people are getting the right drug, at the right dose, at the right time, for the right condition.

To begin the prior authorization process, visit the FACET website.

For questions about prior authorization, contact Cubic Health.

View the list of specialty drugs that require prior authorization

This list will be updated regularly as new drugs come to market.

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