Prior Authorization FAQs

How do I submit a Prior Authorization?

A prior authorization can be submitted via fax or mail or by calling member services for drug specific prior authorization form. Please send supporting clinical documentation to the following address or fax:

CerpassRx

5904 Stone Creek Drive, Ste. 120

The Colony, Texas 75056.

Fax: (469) 592-6460

For faster serice please call CerpassRx Member Services at 844-622-1797 for a drug specific prior authorization form.

Helpful tips for fax prior authorization submission

1) please include only one member per request

2) include only one prescription per request

3) include relevant supporting clinical documentation

4) check form for missing information and accuracy, and fax to (469) 592-6460.

What happens if I do not agree with the decision?

You have the right to appeal the decision. You must appeal the decision in writing within the 180 days following the date of a communication. You may also work with your patient to evaluate therapeutic alternatives when appropriate. If you elect to appeal, please make sure to include all pertinent clinical information regarding your health and medication history that should be evaluated to render a decision. Insufficient information could postpone a decision or lead to a subsequent denial.

There are two types of appeals that you may request

Standard (15 days) – You can request a standard appeal, which means that 15 days after receiving your request for an appeal, we must inform you of our decision.

Fast (48 hours) – You can request an expedited appeal if you believe that your patient’s health could be at risk if you have to wait 15 days until a decision is made. In case of an expedited appeal, a decision must be made within 48 hours or less of receiving your request for an appeal.

If any documentation submitted states that a waiting period of 15 days impacts the health of your patient or the patient would be in danger, we will automatically grant a fast appeal.

What should I include in my appeal?

 In your written request for an appeal, you must include: patients name, address, identification number, the reason for the appeal, and any evidence you wish to attach. You can submit medical reports, supporting letters, or other information that contributes to your case. You can submit the information by mail or via fax.

How do I file an appeal?

An appeal must be filed in writing by sending a letter with your allegations and contract number to the following address or fax:

CerpassRx

5904 Stone Creek Drive, Ste. 120

The Colony, TX 75056

Fax: (469) 592-6460

Who may file a request for an external review?

 You may file a request for an external review for your patient. You will receive more information about how to request an independent review if your appeal is denied by the plan, or you may contact us.

What if the plan denies your appeal again?

 For most types of claims, you have the right to request an independent external review of our decision no later than 120 days from the date of notification of the adverse outcome of your appeal. Contact CerpassRx with any questions you may have about your patients right to an external review.

Who do I contact if I have any additional questions?

Please contact CerpassRx Member Services at 844-622-1797 with any questions.

See which medications are covered

Exclusive Pharmacy Network

(Special member discounts at Alto Pharmacy)

Alto pharmacy will continue to serve the THT membership as an exclusive pharmacy with always free home delivery. Contact Alto today at Call Alto Pharmacy at (800) 874-5881 to register an account & transition your prescription.

Other Pharmacies Include

  • CVS
  • Walmart
  • Smith’s Pharmacy
  • Albertson’s
  • Lins
  • Vons pharmacies.

Interested in a cost savings tip? Prescribe a generic.

It’s just the same, without the name, and the savings based on cost of the drug can be substantial.