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Prior Authorization

SummaCare requires prior authorization on certain drugs and services that are covered under the medical benefit.

Prior Authorization for Drugs Covered Under the Medical Benefit

Certain drugs require prior authorization in order to be covered under by SummaCare. Prior authorization review is the process of determining the medical necessity of a proposed procedure, surgery or treatment (including prescribed drug intervention) relative to approved criteria. Prior authorization is required to ensure that the drug is medically necessary. Find out what prescription drugs under the medical benefit require prior authorization and access the request form.

Prior Authorization for Services

SummaCare utilizes one prior authorization list for all fully-insured PPO health insurance plans and Medicare plans. Prior authorization requests require information which is necessary for a prior authorization determination. Learn more and access the appropriate forms when requesting prior authorization for services.

To view prior authorization lists for self-funded groups, please login to your admin account and click on "Provider Documents" after logging in.

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Provider Support Services

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Provider Engagement Specialists

If you have not met with your assigned Provider Engagement Specialist or would like to schedule an in-office training or meeting to address any questions regarding the authorization process, claims issues, appeals, SummaCare products/benefits or Plan Central training, please contact the assigned Provider Engagement Specialist for your office.

Plan Central

View patient eligibility, benefits, claims status, and self-funded prior authorization lists, as well as review clinical edits and clarifications.