Please note: More information may be requested upon your completion and submission of the applicable form(s).
Applicable to requests submitted via Plan Central for Commercial and Marketplace plans: Determinations and responses for requests submitted electronically will be made within 48 hours for urgent requests and 10 calendar days for non-urgent requests from the time the request is received by SummaCare with all information necessary to support the prior authorization request.
To view prior authorization lists for self-funded groups, please visit Plan Central and click on "Related Documents" after logging in.
Prior authorization is required for certain 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 drugs are developed and approved by a panel of practicing physicians and pharmacists. The drugs covered under the medical benefit are typically administered in an office, home, or outpatient setting.
You can also download a PDF version of the Medical Prior Authorization List which lists those drugs requiring prior authorization that are covered under the medical benefit, as well the prior authorization request form.
Prior Authorization List for Drugs Covered Under the Medical Benefit - Commercial
Prior Authorization List for Drugs Covered Under the Medical Benefit - Medicare
Prior Authorization Request Form for Drugs Covered Under the Medical Benefit
Unless otherwise stated, please call the Authorization Unit at 330.996.8710 to initiate the prior authorization process for these items.
Normal business hours for prior authorizations and admission authorizations are 8:30 A.M. – 5:00 P.M. Monday through Friday. Routine requests to authorize services can be sent via fax to 234.542.0815 using the Authorization Request Form for Service.
For urgent/expedited requests, call 330.996.8710 or 888.996.8710. After normal business hours and on weekends and holidays routine requests are to be sent via fax to 234.542.0815.
For urgent/expedited requests, nursing home authorizations or inter-facility transfers on weekends/holidays, call 330.414.1653. If a physician determines that care is indicated urgently before authorization can be obtained, then SummaCare will retrospectively review the authorization request on the next business day.
After-hours authorizations for emergency hospital admission may be obtained by calling SummaCare’s 24-hour Nurse Line: 800.379.5001.