Preauthorization Guidelines

Preauthorization (sometimes referred to as precertification or prior authorization) is a process that requires a provider or covered individual to obtain approval from DMBA before receiving specific items and services. The medical and surgical services subject to preauthorization may vary by plan and/or employer group.

Please call DMBA at 801-578-5600 or 1-800-777-3622 if you have questions about preauthorization.

Specialty Drug Requests

Some specialty drugs require preauthorization through Archimedes Rx for patients on Deseret Choice Hawaii, Deseret Premier, Deseret Protect, Deseret Select, and Deseret Value. The list of these drugs can be found here. For more information about the medical pharmacy drug program, click here. To request preauthorization, call Archimedes Rx at 1-888-504-5563.

Specialty drugs not included on the medical pharmacy drug list may require preauthorization through Navitus Health Solutions. For questions, please call Navitus at 1-833-354-2226.

Deseret Alliance participants enrolled in the Navitus MedicareRx (PDP) may be required to preauthorize specialty pharmacy medications. Deseret Alliance participants may use any Navitus-contracted specialty pharmacy, but we recommend Lumicera Health Services. To contact Lumicera, call 1-855-847-3554 or fax 1-855-847-3558.

Preauthorization Procedures

Requests for preauthorization can be submitted using DMBA’s online Provider Authorization Request Tool. Upon successful submission, a provider will receive a nine-digit tracking number. The tracking number is verification that DMBA has received the request. This is not an authorization. Providers must not bill or perform a procedure until DMBA has provided written approval.

Once approved, the authorization is valid for a certain length of time (usually 90 days) as outlined in DMBA’s written authorization. Services falling outside of the approved authorization period require the provider to submit a new request. If the request for services is not approved, the participant may choose to go forward with the procedure or service, but the plan will not cover it.

If preauthorization for a service is not obtained, it could result in payment denials for the healthcare provider or reduced benefits for the participant. Services or medications provided without preauthorization may be subject to retrospective review. Providers should verify benefits and authorization requirements with DMBA before providing services.