Prior Authorization

Commercial, BadgerCare Plus and Medicaid SSI plans.

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Guidelines for Prior Authorization

Below are Group Health Cooperative of Eau Clare's Prior Authorization Guidelines for all commercial, BadgerCare Plus and Medicaid SSI plans.

Please note the following: 

  • Authorization for services DOES NOT guarantee payment for services. Payment for services is dependent on other non-medical criteria including benefits associated with a member’s specific plan and eligibility issues.

  • According to Federal Law (Section 1902(n)(3)(B) of the Social Security Act, as modified by section 4714 of the Balanced Budget Act of 1997), providers may not balance bill Medicaid members

  • If a member receives services that require an approved authorization by the Cooperative and such authorization is not obtained, or the authorization request was denied because services were not deemed medically necessary, all services (including out-of-network and future related services and/or follow-up care related to the services) will be denied. This includes any ancillary, facility, and/or professional charges.

  • Cooperative Advantage/D-SNP Providers: For all Medicare enrollees, hospitals must deliver valid, written notice of an enrollee's rights as a hospital inpatient, including discharge appeal rights, using the standardized form, CMS Form R-193, An Important Message from Medicare (IM). Furthermore, Hospitals and Critical Access Hospitals (CAHs) are required to provide written and verbal explanation to Original Medicare and Medicare Advantage enrollees who receive observation services as outpatients for more than 24 hours. Links to these documents can be found below:

    FFS & MA IM | CMS - An Important Message from Medicare (IM)

    FFS & MA MOON | CMS - Medicare Outpatient Observation Notice (MOON)

Pharmaceutical Management Procedures

The processes outlined below refer to how the Cooperative manages drugs that are part of the medical benefit (not part of the pharmacy benefit).

Covered drugs: Drugs covered under the medical benefit have an open formulary meaning we considered all drugs for coverage. Most require prior authorization as outlined in this guideline and are reviewed for medical necessity.

Copayment information, including tiers: Medicaid members do not have copays or tiers for drugs managed under the medical benefit. Commercial members may have cost share and tiering. Please refer to your schedule of benefits that outlines this information.

Drugs that require prior authorization: For a list of drugs that require prior authorization, please see the list in this guideline.

Limits on refills, doses or prescriptions: There may be limits on refills, doses or prescriptions in our process for management of drugs covered under the medical benefit based on FDA prescribing guidelines.

Exception requests: Exception requests are not applicable for the pharmaceuticals that are covered under the medical benefit because it is not a closed formulary.

Use of generic substitution, therapeutic interchange or step-therapy protocols: There are no generic substitution or therapeutic interchange in our process for management of pharmaceuticals covered under the medical benefit. Step therapy protocols do apply and are outlined in our policies for the respective pharmaceutical, which are available here.

How formulary updates are communicated, and how often, if the organization has scheduled formulary updates: Because we have an open formulary, updates to the formulary are not applicable. Providers will receive information on our drug management processes annually in the Provider Manual. Any updates to our management processes will be sent via email.  Members will receive information on our drug management processes annually through the mail. Any updates to members on our management processes will be sent via email or mail.

Forms, Guidelines, and Resources

2025 Prior Authorization Guidelines
Express Scripts, Inc. Prior Authorization Resources
Provider Forms and Resources
UM Policies and Procedures