Utilization Management, Appeals, and Grievances

Certain drugs need prior approval or exceptions to be covered. Learn about coverage determination steps and find forms. Read more about our utilization management requirements, how to request an appeal and where to file a grievance.
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Questions? Contact Capital Rx Customer Service at (833) 502-3346

Exceptions Request

Certain medications may require prior authorization or other utilization management review to determine coverage under the member's pharmacy benefit. Members or their providers may be required to provide additional information to determine if the medication is covered under the member's pharmacy benefit. You may request a prior authorization exception or coverage determination review by calling Capital Rx at (833) 502-3346 TTY Line Monday – Friday: 6 AM – 7 PM CST, Saturday – Sunday: 7 AM – 4 PM CST, Major Holidays: 7 AM – 4 PM CST.

Utilization Management Requirements

Medication Management or Utilization Management Requirements are for certain prescription drugs with special rules that restrict how and when the plan covers them. A team of doctors and pharmacists developed these requirements to help our members use drugs in the most effective ways. These special rules also help control overall drug costs, which keeps your drug coverage more affordable.

In general, our rules encourage you to get a drug that is safe and works for your medical condition. Whenever a safe, lower-cost drug will work medically just as well as a higher-cost drug, the plan’s rules are designed to encourage you and your doctor to use that lower-cost option.

Please refer to our Commercial Capital Rx Formulary to determine specific drug coverage information. 

Examples of Utilization Management

Prior Authorization Program

Most pharmacy benefit plans include the Prior Authorization program. Prior authorization helps encourage the appropriate and cost-effective use of certain drugs by allowing coverage only after clinical criteria are met.

Drugs requiring prior authorization are designated in the Formulary by "PA" (Prior Authorization) under the Restrictions information. These drugs require prior authorization before members can obtain them as a covered benefit. Drugs requiring prior authorization are subject to change. Please contact Capital Rx Health Solutions for a current list of drugs requiring prior authorization and for their coverage criteria. If prior authorization is required, the physician (or his/her representative) must call Capital Rx Customer Service at (833) 502-3346 or fax the request with supporting clinical information to Memorial Hermann Health Solutions pharmacy benefit manager at (833) 434-0563.

Download a Prior Authorization Request

Alternatively, you can visit the Provider Portal to find the Prior Authorization forms.

Quantity Level Limits

Some drug products may be subject to quantity level limits based on the drug manufacturer's packaging size or adopted clinical guidelines. These drugs are designated in the Formulary by "QL" (Quantity Limits) under the Restrictions information. The purpose of these maximum quantity limits is to ensure the proper billing of products and encourage the use of therapeutically indicated drug regimens. Quantity level limits are subject to change.

Please contact Capital Rx Customer Service at (833) 502-3346 for more information.

Step Therapy Limits

In some cases, Memorial Hermann Health Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Memorial Hermann Health Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, the plan will then cover Drug B.

Please contact Capital Rx Customer Service at (833) 502-3346 for more information.

Utilization Management Updates

Formulary changes can happen as often as on a monthly basis and are updated on our formulary and on the document accessible below to serve as a way for our members, providers, and other members of the healthcare team to review these updates, see the changes in prior authorization requirements or process, along with the date or time the changes will become effective.

  • Review current updates to Utilization Management or Prior Authorization Criteria here (Coming Soon).
  • Review our formulary here.
  • Review our prior authorization approval and denial rates for the previous calendar year here.

Appeals

For more information about Pharmacy Appeals, please call Capital Rx at (833) 502-3346 during Monday – Friday: 6 AM – 7 PM CST, Saturday – Sunday: 7 AM – 4 PM CST, and Major Holidays: 7 AM – 4 PM CST.

Grievances

For more information about Pharmacy Grievances, please call Capital Rx at (833) 502-3346 24 hours a day/7 days a week/365 days a year.

Additional Information

If you have questions about Utilization Management restrictions, such as Step Therapy or Prior Authorization, please call Customer Service on the back of the member ID card.

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