Change in Process for Requesting Coverage of a Prior Authorization or Step Therapy Drug

This memo serves as notification to Gateway Health Plan®’s provider network regarding a change in process for requesting coverage of a prior authorization or step therapy drug. Effective immediately, please begin to use the drug specific prior authorization and step therapy forms available on Gateway’s website when submitting a request for a prior authorization or step therapy drug. Below is a user guide for how to access the prior authorization and step therapy forms.

1. Go to www.gatewayhealthplan.com
2. Click on the Rx Drug List tab, located on the right side of the page under Quick Links
3. Select the formulary you would like to view under the heading “For Providers of:”
4. Select either Medicaid or Medicare Assured^® HMO
5. Once at the Medicaid or Medicare page, click on the Search Drug List link
6. Search for the medication you would like to submit a request to Gateway for prior authorization or step therapy override (e.g. Humira or Cymbalta)
7. On the right hand side under the notes column, click on the notes (it may indicate PA=prior authorization, ST=step therapy, or QL=quantity limit)
8. To retrieve the drug specific form, click on Download Authorization Form or Download Step Therapy Form
9. Print the form
10. Complete all requested information on the form, including progress notes, laboratory test results, or chart documentation as necessary or requested.
11. Fax the form into Gateway’s Pharmacy Department at 1-888-245-2049 for processing

* Please continue to use the Non-formulary Drug Exception Form when requesting coverage of a non-formulary drug. The Non-formulary Drug Exception Form can also be accessed on Gateway’s website under the Forms section.
For Medicaid: http://www.gatewayhealthplan.com/providers/pa/formsma.aspx
For Medicare:
http://www.gatewayhealthplan.com/members/pa/forms.aspx

If you need to speak to a Pharmacy Services Representative, please call 1-800-528-6738, Monday through Friday, 8:30 a.m.-4:30 p.m.