Pharmacy Drug Benefit Help Desk
The Pharmacy Benefit Help Desk team provides clinical coverage determination for drugs that are not covered for patients under their plan (prior authorization required or non-formulary) based on the information you provide within required timeframes for coverage determinations.
We use the formulary that is managed by our Pharmacy and Therapeutics Committee.
The responsibility of the Pharmacy Benefit Help Desk is to apply consistent criteria to the use of non-formulary and restricted agents. Our goal is to facilitate the appropriate, cost-effective use of drugs.
Despite phone/fax outreaches to providers offices to obtain the necessary clinical information to help make a coverage determination, some cases are denied because providers are not submitting specific information as it pertains to the drug criteria. When this happens, members and their prescribers are sent a denial letter explaining the reason for the decision and an explanation of appeal rights.
Before appealing, there are steps providers can take:
- Talk to your patient about options for other medications or supplies. If there are covered options on the formulary (approved drug list), they are listed in the denial letter. There may be other options listed that also require a review. Non-prescription drugs or lifestyle alternatives may also be suggested.
- You can submit new or more clinical information to ask us to re-review our decision. If you have new or additional clinical information that explains how the requested medication or supply meets the standards for coverage or medical necessity, you can fax it to the Pharmacy Drug Benefit Help Desk at 1-866-510-1765 or 206-901-4617. We will re-review this request based on the new information.
Frequently asked questions:
When do I need to contact the Pharmacy Benefit Help Desk?
If you prescribe a formulary medication that needs a prior authorization or a non-formulary medication, the provider or the provider’s team member can contact the Pharmacy Benefit Help Desk to provide us with necessary information so we can assess if patient meets criteria.
How do I know Kaiser Permanente Washington’s criteria for medications?
Kaiser Permanente Washington’s non-Medicare drug criteria can be found on www.epocrates.com. You can register free of charge.
How can I contact the Pharmacy Benefit Help Desk?
There are several ways a prescriber (or prescriber’s team member) can obtain authorization for restricted or non-formulary drugs:
- Call: Provide the rationale for why the drug is needed. Our team will refer to established treatment criteria and will approve or deny the request.
- Fax: To request authorization for a formulary prior authorization (restricted) or non-formulary drug, fax your request using the Pharmacy Help Desk Request for Authorization Form.
- Document on the prescription how you have met the restriction criteria for the given drug: Please include clear documentation of the rationale of the drug choice along with the prescription.
- E-mail: Send an email to Pharmacy Help Desk for questions or clarifications.
My Prior Authorization Drug Request for non-Medicare plans was denied. What are my next steps?
You can resubmit any additional information back to us for a new review if there is new or additional information you did not provide on the initial request.
My Prior Authorization Drug Request was denied. How can I determine the preferred alternative?
On the denial letter you receive, we have preferred alternatives if applicable as well as the criteria for the medication you requested.
Contact us: Phone Number: 1-800-729-1174 Fax Number: 1-866-510-1765 Medicare Part D Fax Number: 1-866-439-0050
E-mail: Pharmacy Help Desk
Hours of operation: Monday through Friday 7 a.m. to 6 p.m. Saturday 8:30 a.m. to 5 p.m. Sunday 8:30 a.m. to 5 p.m.
Content on this page is from the provider manual | Disclaimer