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Approval decisions for PA and MN content are developed by the Clinical Pharmacy Advisory Committee (CPAC) with Centene Health Plans and governed through Corporate and Health Plan Pharmacy and Therapeutics (P&T) Committees. Prescribers submit information aligned with the criteria; Envolve Pharmacy Solutions performs initial screening, followed by licensed pharmacist determinations. Responses occur within 24 hours, with faxed notifications, documented decisions, appeal rights, and denial reasons communicated to both prescribers and members.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":51,"@type":70,"position":76},"https://docshare.wps.com/template/general/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/pharmacy-prior-authorization-and-medical-necessity-criteria-ccphar08/283852/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/pharmacy-prior-authorization-and-medical-necessity-criteria-ccphar08/283852.png","ImageObject",442,249,{"name":88,"@type":89},"Tawan","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-21","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":9},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What is the purpose of the prior authorization (PA) and medical necessity (MN) criteria?","Question",{"text":108,"@type":109},"The criteria promote clinically appropriate use of selected high-risk and/or high-cost medications and support program exception requests for drugs not on the Health Plans' Preferred Drug List (PDL).","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Who develops and approves PA and MN criteria content?",{"text":113,"@type":109},"Criteria for drugs are developed by the Clinical Pharmacy Advisory Committee (CPAC) with Centene Health Plans, and the Corporate and Health Plan P&T Committees must approve the guidelines before implementation.",{"name":115,"@type":106,"acceptedAnswer":116},"How quickly are PA and MN requests responded to, and how are denials handled?",{"text":117,"@type":109},"PA and MN requests are responded to within 24 hours. 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The criteria for approval have been established by the Clinical Pharmacy Advisory Committee (CPAC), in conjunction with the Centene Health Plans and are approved through both the Corporate and Health Plan Pharmacy and Therapeutics (P&T) Committees. Decisions on PA and MN criteria content are coordinated with input from pharmacy and medical practitioners, Centene Health Plan representatives, and review of current available medical literature and professional standards of practice.  \nPA policies approved by CPAC that have not yet been presented at the Corporate P&T Committee are considered to be interim PA policies. Pharmacists reviewing PA requests use interim criteria as reference when evaluating coverage requests until the criteria are reviewed and approved at Corporate P&T.  \nPOLICY:  \n􀁸 The Centene Corporate and Health Plan P&T Committees make the final decisions regarding which medications are included on the PDL and of these, which require PA for approval. Criteria for all drugs are developed for approval by the CPAC. The respective approval criteria are labeled either PA or MN criteria. The Corporate and Health Plan P&T Committees must approve the prior authorization and medical necessity guidelines before implementation.  \n􀁸 In order for a PA or MN medication to be covered, the prescriber must submit information consistent with the developed criteria to obtain approval for the medication. A form for submission of a PA or MN request is posted on Health Plan web sites (see Attachment A, Envolve Pharmacy Solutions Medication Prior Authorization Form) . Use of this form is not a requirement but provided only as guidance on the information that may be necessary to assure prompt review of a PA or MN request.  \n􀁸 Initial PA and MN requests are reviewed by a Certified Pharmacy Technician (CPhT) or a licensed Clinical Pharmacist at Envolve Pharmacy Solutions for a determination of meeting criteria. For requests that meet initial screening criteria, an authorization for approval is  \n\n| 02/10, 02/11, 02/12, 11/12, 02/13, 02/14, 08/14, 08/15, 08/16, 09/16, 11/16, 11/17, 08/18, 05/19, 08/20, 11/20, 01/05/21, 08/21, 11/21 |  |\n| --- | --- |\n| PRODUCT TYPE: Medicaid | PAGE: Page 2 of 8 |\n\nentered in the Envolve Pharmacy Solutions prior authorization system and the prescriber is notified via fax that approval has been granted.  \n􀁸 When a request does not meet criteria, it is forwarded to a licensed Envolve Pharmacy Solutions Clinical Pharmacist for a final determination. Clinical Pharmacists review all denials.  \n􀁸 For clients that reside in a state that does not allow pharmacists to deny a prior authorization request, the requesting prescriber is notified via fax that the request will be forwarded to the health plan or other appropriate reviewer for further review, evaluation and a decision, for requests that cannot be approved.  \n􀁸 PA and MN requests are responded to within 24 hours. If all necessary information to review the request is not received in a timely manner, the request will be reviewed with the available information by the reviewer and a decision rendered with","cbCaijL3yfebq9Ia","https://ap.wps.com/l/cbCaijL3yfebq9Ia","pdf",248817,8,"English","# Scope\n## Purpose\n# Policy\n## Roles and decision workflow\n## Submission requirements and forms\n## Timelines and notification process\n## Denials, documentation, and appeals","[{\"question\":\"What is the purpose of the prior authorization (PA) and medical necessity (MN) criteria?\",\"answer\":\"The criteria promote clinically appropriate use of selected high-risk and/or high-cost medications and support program exception requests for drugs not on the Health Plans' Preferred Drug List (PDL).\"},{\"question\":\"Who develops and approves PA and MN criteria content?\",\"answer\":\"Criteria for drugs are developed by the Clinical Pharmacy Advisory Committee (CPAC) with Centene Health Plans, and the Corporate and Health Plan P\\u0026T Committees must approve the guidelines before implementation.\"},{\"question\":\"How quickly are PA and MN requests responded to, and how are denials handled?\",\"answer\":\"PA and MN requests are responded to within 24 hours. If denied, the prescriber receives a fax within 24 hours with the reason and appeal rights, and the member denial letter is mailed with similar appeal and external review information.\"}]","Pharmacy Prior Authorization and Medical Necessity Criteria - CC.PHAR.08 | PDF",1789620896]