Supporting the Members Who Rely on Our Care

HIPAA Authorization Form

The following are lists of the most commonly prescribed medications. They represent an abbreviated version of the drug list (formulary) that is at the core of each prescription-drug benefit plan. These lists are not all-inclusive and do not guarantee coverage. In addition to drugs on these lists, the majority of generic medications are covered and members are encouraged to ask their doctor to prescribe generic drugs whenever appropriate. 

Benefit plan designs, coverage determinations, copay amounts, and other plan-specific details may vary by plan. For the most accurate information about your prescription drug coverage, please refer to your annual benefit enrollment materials or log in to your member portal.

• ACA Preventative Care Medications  
• 2025 Premium Formulary — Comprehensive UM
• 2025 Premium Formulary – Flex UM 
• 2025 Select Formulary – Focused UM

Some medications may require prior authorization (PA) before they are covered under your pharmacy benefit. This process ensures that the prescribed medication is safe, effective, and appropriate for your condition. 

What is prior authorization?
Prior Authorization is a requirement that your doctor or prescriber get approval from the prescription benefit provider before certain medications are covered. This process helps promote safe and cost-effective use of prescription drugs. 

Common Reasons a Medication May Require PA:  

• The medication has potential for misuse or abuse 
• The medication has a  very high cost 
• There is a lower-cost alternative available 
• The medication is approved only for specific diagnoses or conditions 
• The medication is not typically used as a first-line treatment 

How to Request Prior Authorization:
Contact your provider (doctor or prescriber) to request they submit supporting documentation for your prior authorization request. Your provider needs to answer questions about the use of the requested medication and submit medical records for the prior authorization process.   

Here are the ways a prior authorization request may be submitted: 

1. Submit electronically through an ePA platform:
   • CoverMyMeds
   • Surecsripts
2. Submit the request and documentation through our online portal, PromptPA 
3. Download the Prior Authorization Form and fax the completed PA form to: 
   • SlateRx Clinical Services Fax Number: 866-351-1617
4. Call the prior authorization team at: 
   • SlateRx Clinical Services Department Phone Number: 833-789-9236 M-F 9 am to 9 pm ET or weekends 9am to 1pm ET 

If you wish to submit a Prior Authorization request, please contact SlateRx Clinical Services Department at 833-789-9236.  Your provider will still need to answer questions about the use of the requested medication and submit medical records on your behalf.  

How long does it take?
Most requests are completed within 3 to 7 business days after all required information is received from your doctor, with many being reviewed within 72 hours. You will be notified of the decision via mail, or phone if requested, and your provider will be notified of the decision by fax.  

If Approved: You can fill your prescription at your pharmacy as usual.  

If Denied: You and your provider will receive a denial letter explaining why the medication was not approved. Your provider or appointed representative may: 

• Appeal the decision by providing additional information to support the request 
• Prescribe an alternative medication 

What medications require a PA?
To review medications that require a PA you may reference an abbreviated version of the drug list (formulary) that that was chosen by your prescription-drug benefit plan. These lists are not all-inclusive and do not guarantee coverage. In addition to drugs on these lists, the majority of generic medications are covered, and members are encouraged to ask their doctor to prescribe generic drugs whenever appropriate.  

Benefit plan designs, coverage determinations, copay amounts, and other plan-specific details may vary by plan. For the most accurate information about your prescription drug coverage, please refer to your annual benefit enrollment materials or log in to your member portal.

Coverage Determination Forms:

• Non-formulary Exception Request
• Prior Authorization Request
• Quantity Limit Exception 
• Step Therapy Exception

Need help?
If you have questions about the PA process, please contact the Clinical Services Department: 

• Phone: 833-789-9236 
• Hours of Operation:  
  • Monday – Friday 9am-9pm ET;  
  • Saturday & Sunday 9am-1pm ET 
• Or visit our contact page: https://slate-rx.com/contact 

What are clinical criteria?
Clinical criteria help determine if a medication is right for your condition. These criteria are developed by licensed pharmacists and physicians based on current clinical evidence-based guidelines, medical literature, FDA-approved labeling, and drug compendia. 

If a drug requires prior authorization, step therapy, or quantity limits, clinical criteria help guide those decisions. 

SlateRx Clinical Criteria Standards: 
All utilization reviews are performed using evidence-based guidelines and clinical standards. Our criteria are developed in accordance with the following, for example: 

• Nationally recognized guidelines, such as those from the U.S. Food and Drug Administration (FDA), National Comprehensive Cancer Network (NCCN), American College of Cardiology (ACC), and others. 
• Peer-reviewed medical literature 
• Standard medical and pharmacy practice guidelines 
• Drug manufacturer labeling and package inserts 

The clinical guidelines are developed and reviewed by a team of licensed physicians and pharmacists who specialize in various therapeutic areas. 

SlateRx Utilization Review Standards: 
Utilization Review (UR) is a process we use to assess whether a prescribed drug is: 

• Medically necessary 
• Clinically appropriate 
• Covered under your benefit plan 

Each request is reviewed on a case-by-case basis by qualified clinical staff. SlateRx clinical staff, who are comprised of qualified pharmacists or physicians, evaluate your medical history, age, comorbidities, treatment progress, and personal care environment along with the clinical criteria to decision your medication request.  

SlateRx does not reward practitioners who perform utilization reviews for issuing denials of coverage or care. Utilization review decisions are based only on appropriateness of care, service, and existence of coverage.  

Your Rights:
You have the right to: 

• Request a copy of the clinical criteria used in making an adverse decision related to your medication coverage request. 
• Request an appeal if a medication is denied coverage through the utilization review process. 
• Request  a specialist reviewer for your appeal request. 

Requesting Clinical Criteria:
Clinical criteria are available upon request to both members and healthcare providers. 

To request a copy of the clinical criteria used to evaluate a specific medication: 

• Call SlateRx Clinical Services Department Phone Number: 833-789-9236, or 
• Contact your healthcare provider, who may also request this information on your behalf. 

Prior Authorization is a requirement that your doctor or prescriber get approval from the prescription benefit provider before certain medications are covered. This process helps promote safe and cost-effective use of prescription drugs.

• The medication has potential for misuse or abuse.
• The medication has a very high cost.
• There is a lower-cost alternative available.
• The medication is approved only for specific diagnoses or conditions.
• The medication is not typically used as a first-line treatment.

Contact your provider (doctor or prescriber) to request they submit supporting documentation for your prior authorization request. Your provider needs to answer questions about the use of the requested medication and submit medical records for the prior authorization process.

Here are the ways a prior authorization request may be submitted:

1. Submit electronically through an ePA platform:
   • CoverMyMeds
   • Surecsripts
2. Submit the request and documentation through our online portal, PromptPA
3. Download the Prior Authorization Form and fax the completed PA form to:
   • SlateRx Clinical Services Fax Number: 866-351-1617
4. Call the prior authorization team at:
   • SlateRx Clinical Services Department Phone Number: 833-789-9236 M-F 9 am to 9 pm ET or weekends 9am to 1pm ET

If you wish to submit a Prior Authorization request, please contact SlateRx Clinical Services Department at 833-789-9236. Your provider will still need to answer questions about the use of the requested medication and submit medical records on your behalf.

Most requests are completed within 3 to 7 business days after all required information is received from your doctor, with many being reviewed within 72 hours. You will be notified of the decision via mail, or phone if requested, and your provider will be notified of the decision by fax.

If Approved: You can fill your prescription at your pharmacy as usual.

If Denied: You and your provider will receive a denial letter explaining why the medication was not approved. Your provider or appointed representative may:

• Appeal the decision by providing additional information to support the request
• Prescribe an alternative medication

To review medications that require a PA you may reference an abbreviated version of the drug list (formulary) that that was chosen by your prescription-drug benefit plan. These lists are not all-inclusive and do not guarantee coverage. In addition to drugs on these lists, the majority of generic medications are covered, and members are encouraged to ask their doctor to prescribe generic drugs whenever appropriate.

Benefit plan designs, coverage determinations, copay amounts, and other plan-specific details may vary by plan. For the most accurate information about your prescription drug coverage, please refer to your annual benefit enrollment materials or log in to your member portal.

Coverage Determination Forms:

• Non-formulary Exception Request
• Prior Authorization Request
• Quantity Limit Exception 
• Step Therapy Exception

Clinical criteria help determine if a medication is right for your condition. These criteria are developed by licensed pharmacists and physicians based on current clinical evidence-based guidelines, medical literature, FDA-approved labeling, and drug compendia.

If a drug requires prior authorization, step therapy, or quantity limits, clinical criteria help guide those decisions.

All utilization reviews are performed using evidence-based guidelines and clinical standards. Our criteria are developed in accordance with the following, for example:

• Nationally recognized guidelines, such as those from the U.S. Food and Drug Administration (FDA), National Comprehensive Cancer Network (NCCN), American College of Cardiology (ACC), and others.
• Peer-reviewed medical literature
• Standard medical and pharmacy practice guidelines
• Drug manufacturer labeling and package inserts

The clinical guidelines are developed and reviewed by a team of licensed physicians and pharmacists who specialize in various therapeutic areas.

Utilization Review (UR) is a process we use to assess whether a prescribed drug is:

• Medically necessary
• Clinically appropriate
• Covered under your benefit plan

Each request is reviewed on a case-by-case basis by qualified clinical staff. SlateRx clinical staff, who are comprised of qualified pharmacists or physicians, evaluate your medical history, age, comorbidities, treatment progress, and personal care environment along with the clinical criteria to decision your medication request.

SlateRx does not reward practitioners who perform utilization reviews for issuing denials of coverage or care. Utilization review decisions are based only on appropriateness of care, service, and existence of coverage.

You have the right to:

• Request a copy of the clinical criteria used in making an adverse decision related to your medication coverage request.
• Request an appeal if a medication is denied coverage through the utilization review process.
• Request a specialist reviewer for your appeal request.

Clinical criteria are available upon request to both members and healthcare providers. To request a copy of the clinical criteria used to evaluate a specific medication:

• Call SlateRx Clinical Services Department Phone Number: 833-789-9236, or 
• Contact your healthcare provider, who may also request this information on your behalf. 

If you have questions about the PA process, please contact the Clinical Services Department:

• Phone: 833-789-9236
• Hours of Operation:
  • Monday – Friday 9am-9pm ET;
  • Saturday & Sunday 9am-1pm ET
• Or visit our contact page: https://slate-rx.com/contact

SlateRx a is a pharmacy services provider that administers prescription drug coverage for plans and members across the nation. For some groups, SlateRx administers the whole pharmacy benefit. For others, SlateRx provides only clinical support when certain medications need review. Our goal is to make getting your prescription medications easier. 

A formulary is a list of prescription drugs covered by your plan. Formularies are developed to control costs and ensure the availability of safe, effective, and affordable medications. 

At SlateRx, our formularies are developed based on sound clinical principles, prioritizing safety and efficacy, and are grounded in achieving the best value while upholding the highest standards of clinical care. 

Medications on these lists are grouped into tiers—typically generics, preferred brands, and non-preferred brands. Lower tiers usually mean lower copays. 

Coverage for each of your prescribed medications is outlined in the formulary. Depending on the benefits chosen by your plan sponsor, there can be customizations to serve the needs of the members. To confirm coverage of your medication you can view your drug formulary (list of covered medications) by logging into your member portal or contacting customer service. The formulary lists medications by tier, which affects your out-of-pocket costs. 

If your medication is not covered by your plan, you have a few options:

Check for Covered Alternatives: 

Your doctor may be able to prescribe a similar medication that is covered by your plan. You can review your formulary (list of covered drugs) on your member portal or contact us for help. 

Request a Coverage Exception: 

If your doctor believes the non-covered medication is medically necessary, they can submit a formulary exception request. This includes providing medical justification for why alternatives are not suitable. 

Pay Out-of-Pocket: 

You can choose to pay the full cost of the medication without insurance, but this may be expensive. We recommend exploring the above options first. 

Explore Financial Assistance: 

Some drug manufacturers and non-profits offer savings programs or copay assistance. We can help point you in the right direction if needed. 

Still unsure or need assistance? Call SlateRx Member Services at 833-789-9236 for support.

Brand-name drugs are the original products developed and marketed by a pharmaceutical company. Generic drugs are copies of those brand-name medications and contain the same active ingredients, dosage form, strength, and route of administration. 

Generic drugs work the same way as brand-name drugs and are approved by the U.S. Food and Drug Administration (FDA) for safety, effectiveness, and quality. The main difference is the cost—generics are typically much less expensive because they don’t require the same development and marketing costs as brand-name drugs. 

Choosing generic drugs can help lower your out-of-pocket costs without compromising on quality or effectiveness. In many cases, your plan may encourage or require the use of generics when available. 

Certain drugs require prior authorization to ensure they’re safe, effective, and the most cost-effective treatment. Your doctor must submit documentation explaining why the drug is medically necessary.  

A prior authorization (PA) typically takes 3 to 7 business days once we receive all the required information from your doctor. In some cases, it may be completed sooner. 

However, delays can happen if: 

• Additional medical documentation is needed 
• Your provider hasn’t submitted the request yet 
• The request is submitted outside business hours 

For urgent cases, expedited reviews may be available and completed within 72 hours and in some cases, sooner, depending on your plan and the situation. 

A quantity limit is a restriction on the amount of medication that your plan will cover within a specific time period—usually per prescription, per month, or per 90 days.

These limits are based on FDA-approved dosing guidelines and help ensure safe and effective use of medications. For example, if a medication is typically taken once per day, your plan may limit coverage to 30 tablets per 30 days.

Step therapy requires you to try less expensive or more proven medications before “stepping up” to more costly alternatives. If those don’t work, your doctor can request approval for other treatments.

To allow someone to access your pharmacy benefit information or speak with us on your behalf, you’ll need to complete and submit a HIPAA Authorization Form. This form gives us your written permission to share your protected health information (PHI) with a person you designate — such as a family member, caregiver, or legal representative.

Here’s how to do it:

• Download the HIPAA Authorization Form from your member portal or request a copy by calling Member Services.
• Fill out the form with the name of the person you authorize and the type of information you’re allowing us to share.
• Sign and date the form, then return it by mail, or fax to 866-351-1617
• Once processed, we’ll be able to speak with your authorized representative about your prescription coverage, claims, prior authorizations, and other benefit-related matters.

Therapeutic interchange is the practice of replacing a prescribed drug with a clinically equivalent medication that is approved to treat the same condition but may have different active ingredients.

This usually happens when:

• A lower-cost or preferred medication is available and covered under your plan
• The alternative has the same therapeutic effect
• The switch is supported by clinical guidelines and approved by your prescriber

These substitutions are always reviewed for safety and effectiveness, and your doctor will be consulted before any changes are made.

Therapeutic interchange helps lower medication costs while maintaining quality care. If you or your doctor prefer that you stay on the original medication, your doctor can request a formulary exception.

As a SlateRx member, you have the right to file a complaint, grievance, or appeal if dissatisfied with our services.

Our Customer Care Representatives are dedicated to addressing any concerns you may have. If you wish to express any dissatisfaction, please contact our Customer Care Department at 833-789-9236.

Common concerns include, but are not limited to:

• Quality of your care concern
• Pharmacy wait times/unable to reach your pharmacy
• Inability to locate a pharmacy in your area
• Unable to obtain your prescription within a reasonable amount of time
• Lack of adequate service
• Plan benefit concerns
• Dissatisfaction with the prior authorization process or outcome

As a member, you have the right to: 

• Be treated with respect, dignity, and courtesy in all interactions. 
• Have your personal health and pharmacy information kept private in accordance with federal and state laws, including HIPAA. 
• Receive clear, accurate, and timely information about your pharmacy benefits, including covered and non-covered medications.  
• Know how to access our clinical services and information about coverage decisions. 
• Receive medications covered by your benefit plan, subject to applicable formulary, clinical, and benefit guidelines. 
• File a complaint or appeal adverse decisions without fear of retaliation. 
• Request information in other languages and in alternative formats, free of charge, if you have special needs. 
• Receive prompt and fair responses to requests, inquiries, complaints, and appeals. 

As a member, you are responsible for: 

• Giving complete and accurate information about your health, medications, and insurance coverage. 
• Using your pharmacy benefit according to the rules of your plan, including formulary and prior authorization requirements. 
• Taking medications as prescribed by your healthcare provider. 
• Informing your providers and pharmacists of all medications you are taking, including over-the-counter products and supplements. 
• Treating pharmacy staff, customer service representatives, and healthcare professionals with respect. 
• Actively participating in your care by asking questions, seeking clarification, and following agreed-upon treatment plans. 
• Safeguarding your member identification card and benefit information to prevent misuse. 
• Notifying us of any changes in your contact information, eligibility, or coverage. 

• We provide free services to help you communicate with us.  
• You can request your letters in other languages or in other formats, such as large print, braille or audio.  
• You can ask for an interpreter.  
• You can request language assistance by calling the following phone number: 833-789-9236

We are committed to ensuring that our website and mobile applications are accessible to individuals with disabilities. If you need assistance using our website or mobile applications (including documents), please call 1-844-265-1735, TTY/RTT 711.