Clinical Pharmacy and Specialty Drugs Prior Authorization Programs
Select medications may require notification and review to determine coverage under the member's pharmacy benefit. Members or their providers may be required to provide additional information to Health Plan of Nevada/Sierra Health and Life (HPN/SHL) to determine if the medication is covered under the member's pharmacy benefit. HPN/SHL leverages many UnitedHealthcare policies and the links are below. HPN/SHL also maintains some additional Nevada-specific protocols and the programs are listed at the bottom of this page.
Please note: Although there may be a program or protocol in place, exclusions still apply to some plans for some medications. This information is on the PDL for the specific plan the member has.
PRIOR AUTHORIZATION PROGRAMS
The criteria used to determine benefit coverage for the Notification program is based on FDA approved uses of the medication and medication labeling, which look at drug and diagnosis. Medical Necessity goes beyond drug and diagnosis and takes into consideration other factors. Medical Necessity evaluates the clinical appropriateness of a medication in terms of condition being treated, severity of condition, type of medication, frequency of use and duration of therapy.
When both Notification and Medical Necessity Protocols are available, HPN/SHL uses Medical Necessity Protocols (limited exceptions to this rule are listed below.) For all other medications that require Prior Authorization per the PDL for the member’s specific plan and don’t have a Medical Necessity Protocol, please use the Notification document. Both documents can be found at https://www.uhcprovider.com/en/prior-auth-advance-notification/prior-auth-specialty-drugs/prior-auth-pharmacy-medical-necessity.html.
Please utilize the Notification document for the following three drugs rather than the Medical Necessity Protocol:
STEP THERAPY PROGRAMS
Step Therapy helps to encourage the use of less expensive, but similarly effective medications. Step therapy requires members to try a lower-cost medication (known as step 1) before progressing to a higher-cost alternative (known as step 2).
For all medications that require Step Therapy per the PDL for the member’s specific plan, please use the Step Therapy document located at https://www.uhcprovider.com/en/resource-library/drug-lists-pharmacy/clinical-drug-step-therapy.html.
The following are HPN/SHL Nevada-specific programs.