Important Information About Your Prescription
If you have Health Choices in Pennsylvania:
A list of medications which your health insurance company will pay for is called a formulary.
Each health insurance company has a different list of medications.
Sometimes medications require special permission from the insurance company.
If you take a prescription to a pharmacy and the pharmacist says he/she cannot give you the medication because it needs prior authorization, you have the following rights:
- If this is a new medication, the pharmacist should give you a 3 day supply. Ask the pharmacist to call the doctor to either change the medication or get prior authorization. If the HMO has not answered the doctor in 3 days, they must give you another 3 days until they answer the doctor’s request. If you only get a 3 day supply, be sure to call your doctor to let him know.
- If this is a continuation of an old medication, the pharmacist must give you a 15 day supply while you are waiting for the doctor to get permission for the medication or change the medication. Be sure to call the doctor to say that you need prior authorization or a different medicine.
If the pharmacist does not give you any medication, call your health plan member services number on your card, or the state clinical sentinel, 1-800-xxx-xxxx. If you are unable to obtain help, call the Pennsylvania Health Law Project 1-800-274-3258.
And always call your doctor if you are unable to obtain prescribed medication.
If the doctor requests prior authorization and the request is denied, you may appeal the decision. You will get a letter from the health plan telling you how to do this.
