What if the medication or service the provider requested is denied?
When a request is denied, alternative treatment options which are covered under the benefit plan are suggested to the provider. Each request is reviewed individually and decisions are made based on medically sound clinical criteria developed and/or approved by one of our physician committees. If the prior authorization request for a specific medication is denied, the drug is considered a non-covered benefit. It is not available as a third-tier medication. You have the right to appeal denials and your appeal rights will be contained in the denial letter that you and your provider will receive.
