Prior Authorization

Some medications need extra approval before they’re covered. These may include medications that:

• have strong side effects
• are meant to treat certain health conditions only
• might be misused
• are not on the approved drug list (formulary*) or have more affordable alternatives
• are expensive or require special handling

*A formulary is a list of prescription medications that a health plan covers. It helps guide doctors and patients to choose effective, safe, and affordable medications.

For more detailed information about which medications require prior authorization, you can visit the Medication Policy library on the Ventegra website.

If your medication needs prior approval, start by talking with your doctor. Ask if there are alternative treatments that are fully covered and don’t require prior authorization.

If there aren’t any suitable alternatives, your doctor can submit a prior authorization request to Ventegra. When your doctor sends the first request for medication approval, they will need to include:

• A completed prior authorization form
• Recent clinic notes
• Any lab results that help show why the medication is necessary
• Any test results related to your diagnosis or treatment

Submitting a prior authorization request doesn’t guarantee the medication will be approved for coverage. We acknowledge that this can be frustrating, and we’re here to help you understand your options and guide you through the process.

All prior authorization requests are evaluated by licensed clinical pharmacists using medication criteria that aligns with U.S. Food and Drug Administration (FDA) approvals, current national guidelines, and your employer’s selected benefit coverage.

At Ventegra, we work diligently to review complete requests as quickly as possible. The time frame is dependent on the type of request—for example, whether it’s an initial request or an appeal.

Decision timeline for most plans:

• Non-urgent (standard) Initial Requests: 15 business days
• Urgent Initial Requests: 72 hours
• Non-urgent Appeal: up to 30 business days
• Urgent Appeal: 72 hours

Please check your plan documents for specific details.

If any important information is missing from your request, we won’t be able to make a decision, and the case will be closed temporarily. However, as soon as the missing details are provided, we’ll resume the review process right away to ensure you're back on track.

To check the status of your prior authorization or ask questions, call the pharmacy benefits phone number found on your insurance card. Live support from our Customer Care Team is available Monday – Friday from 4:00 AM to 12:00 AM (PT) and Saturday – Sunday from 7:00 AM to 7:00 PM (PT). You can also reach us via live chat by clicking on the orange chat icon in the bottom right corner of this page.

Once we have made a decision about your request, Ventegra will notify your doctor of the decision within 1 to 2 business days. You’ll receive a letter in the mail within 7 to 10 business days.

If your initial request is denied, your doctor or you can ask for a Level 1 Appeal (L1A) by providing:

• a completed L1A form or a letter explaining why the medication is necessary
• any new supporting medical information

If the Level 1 appeal is denied, a second appeal can be made, and an independent review organization (IRO) will make the final decision. For this appeal, a completed L2A form or letter, along with any new medical information, should be submitted. The IRO’s decision is final and legally binding.

Coverage can vary between plans for several reasons, including:

• The medication may not be on Ventegra’s formulary (list of covered drugs).
• There may be generic or preferred formulary alternatives available.
• Clinical guidelines, such as the medication’s efficacy, or cost data may have changed.
• Ventegra may have different coverage rules, such as requiring prior authorization or having different tiered copay structures.
• Pharmacy network differences—some medications are only covered at certain pharmacies where Ventegra has already negotiated the best prices for you.
• Quantity or day supply limits may differ.