Prior authorization codes, criteria, and utilization and/or clinical policies do not constitute benefit coverage. Information regarding medications may be found on the pharmacy links located on this website. Please refer to your specific Medicare Advantage Evidence of Coverage (EOC) for benefit coverage information.
The Prior Authorization Code “look up”, criteria, and utilization and/or clinical policies provided on this website are intended to help interpret SummaCare Medicare Advantage EOC documents. When determining coverage, the member-specific EOC will always govern.
Utilization management (UM) is a process health plans use to evaluate the medical necessity, appropriateness, and efficiency of healthcare services, procedures and facilities. The process is used to prevent unnecessary or inappropriate care. Some healthcare services require review and authorization by the health plan. SummaCare bases all authorization (concurrent or inpatient, prior authorization, and post service) decisions on reasonable medical evidence and a consensus of relevant healthcare professionals. Clinical decisions about each request for service are based on the clinical features of the individual case and the medical necessity criteria.
Prescription drug benefits incorporate utilization management programs that apply restrictions on certain drugs. These restrictions include, but are not limited to, prior authorization, step therapy and quantity limits.
SummaCare receives routine and expedited/urgent requests to authorize services from 8:30 a.m. to 5:00 p.m. at 330.996.8710 or 888.996.8710 (TTY 711). SummaCare maintains an incoming fax line available 24 hours a day, 365 days a year that is dedicated to receiving incoming authorization requests. Routine requests to authorize services can be made by your provider by faxing the Prior Authorization Request Form for services to 234.542.0815. There also is a convenient fillable online form available for providers to use Prior Authorization Request Form.
For urgent/expedited requests, call 330.996.8710 or 888.996.8710 (TTY 711).
SummaCare also maintains a voicemail inbox to receive requests for authorizations outside of regular business hours (for providers). Communications received after normal business hours are returned on the next business day and communications received after midnight on Monday through Friday are responded to on the same business day.
Prior Authorization and/or Step Therapy may be required for certain Part B drugs because they may have limited conditions for which they are prescribed, special monitoring or dispensing requirements or an extremely high cost. Guidelines for approving coverage for Prior Authorization and Step Therapy are developed and approved by SummaCare’s Pharmacy and Therapeutics Committee, which consists of a panel of practicing physicians and pharmacists. The drugs covered under the medical benefit are typically administered in an office, home or outpatient setting.
Prior Authorization or Step Therapy Request Form for Part B Drugs
List of Part B drugs that require Prior Authorization
List of Part B drugs subject to Step Therapy
Prescription drug benefits incorporate utilization management programs that apply restrictions on certain drugs. These restrictions include, but are not limited to, prior authorization, step therapy, and quantity limits. More on Part D drug coverage and the authorization process can be found here.