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The SelectCare Formulary list covers drugs according to 4 "tiers" or cost-sharing levels.
- Tier 1 is the lowest cost-sharing level and applies to generic drugs only.
- Tier 2 drugs are "preferred drugs" and have a higher cost-sharing level than tier 1 drugs.
- Tier 3 is the non-preferred drug cost sharing level.
- Tier 4 drugs have the highest cost sharing level because they are high-cost/ unique drugs.
- If the member's drug is contained in our non-preferred tier (3), you and/or the member can ask us to cover it at the cost-sharing amount that applies to drugs in the preferred drug tier (2). This would lower the amount you must pay for your drug. Your must provide a statement of medical necessity that explains why the lower tiered drug(s) in that drug class would not be as effective in treating the member's condition and/or would cause the member to have adverse medical effects. You cannot ask SelectCare to cover a non-preferred drug at the generic drug cost sharing level. Also, you may not ask us to cover a tier 4 drug at a lower cost-sharing level.
We will give you and the member a decision within 72 hours of getting your statement of medical necessity for a standard exception request or 24 hours of getting your statement of medical necessity for an expedited exception request.
Providers who would like to submit an exception request may either contact our Provider Help Desk at 1-866-205-0749, or use our physician's coverage determination form available below. Please answer all questions on the form and fax to the phone number listed on the form.
Click here for the Physician's Coverage Determination Request Form, fax or mail the completed form to:
SelectCare
Prior Authorization Department
200 Stevens Drive
Philadelphia, PA 19113
Fax Standard: 1-866-426-7616
Fax Expedited: 1-866-785-3625
What can be done if a Coverage Determination is denied?
If SelectCare denies the coverage determination the member or their representative has the right to request a redetermination appeal. Physicians have the right to request an expedited redetermination appeal on a member's behalf. Please see our section on Appeals and Grievances for information about member appeal rights, or contact our Member Services Department 8:00 a.m. - 8:00 p.m., seven days a week.
| Telephone: |
1-877-661-6230 (Press 2) |
| TTY/TDD: |
1-800-735-2929 |
Click here for more information on Appeals & Grievances.
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