Overview
1. What is Prior Authorization?
Prior Authorization is a program that helps you get prescription drugs you need with safety, savings and — most importantly — your good health in mind. It helps you get the most from your healthcare dollars with prescription drugs that work well for you and that are covered by your pharmacy benefit. It also helps control the rising cost of prescription drugs for everyone in your plan.
The program monitors certain prescription drugs and their costs so you can get the right drug at the right cost. It works much like healthcare plans that approve certain medical procedures before they’re done, to make sure you’re getting tests you need: If you’re prescribed certain medicine, that drug may need a “prior authorization.” It makes sure you’re getting a cost-effective drug that works for you.
For instance, Prior Authorization ensures that covered drugs are used for treating medical problems rather than for other purposes.
Example: A medicine may be in the program because it treats a serious skin condition, but it could also be used for cosmetic purposes, such as reducing wrinkles. To make sure your medicine is used to treat a medical condition and promotes your health and wellness, your plan may cover it only when a doctor prescribes it for a medical problem.
In this program, your own medical professionals are consulted. When your pharmacist tells you that your prescription needs a prior authorization, it simply means that more information is needed to see if your plan can cover the drug. Only your doctor (or sometimes a pharmacist) can provide this information and request a prior authorization.
2. Who decides what drugs to include in my Prior Authorization program?
Your plan has chosen a Prior Authorization program developed under the guidance and direction of independent, licensed doctors, pharmacists and other medical experts. Together with Express Scripts — which manages your pharmacy benefit plan — these experts review the most current research on thousands of drugs tested and approved by the U.S. Food & Drug Administration (FDA) as safe and effective. They recommend prescription drugs that are appropriate for a Prior Authorization program, and your pharmacy benefit plan chooses the drugs that will be covered.
3. What kinds of drugs need a prior authorization in my program?
The ones in your Prior Authorization program are
A. drugs that your plan wants to make sure you need for a medical condition, and
B. drugs that could be used for non-medical purposes.
How Prior Authorization Works
4. Why couldn’t I get my original prescription filled at the pharmacy?
Here’s what occurs when a prescription drug needs a prior authorization:
A. When you hand in your prescription, your pharmacist sees a note on the computer system indicating “prior authorization required.” Your pharmacist lets you know that your prescription needs a prior authorization — which simply means that more information is needed to determine if your plan can cover the drug.
B. What you can do:
You can ask your doctor to call Express Scripts — the company chosen to manage our pharmacy benefit. Only your doctor (or sometimes a pharmacist) can give Express Scripts the information needed to see if your drug can be covered. Express Scripts’ Prior Authorization phone lines are open 24 hours a day, seven days a week, so a determination can be made right away.
OR you can ask your doctor if you could use another medication that’s covered by your plan.
OR you can simply pay full price for the prescription at your pharmacy.
If your doctor (or pharmacist) calls for a prior authorization, an Express Scripts licensed pharmacist will:
·
check your plan’s guidelines to see if your prescription drug can be covered, and
·note whether your plan will cover the drug only when it’s used for treating specific medical conditions, rather than for other purposes.
Your doctor or pharmacist will be asked questions about your specific condition. If the information provided meets your plan's requirements, you pay the plan’s copayment at the pharmacy.
5. I need a prescription filled immediately. What can I do?
At the pharmacy, your pharmacist may tell you that your drug requires prior authorization. If this occurs and you need your medication quickly, you can:
·Talk with your pharmacist about filling a small supply of your prescription right away. You may have to pay full price for this drug.
·Then, ask your pharmacist to contact your doctor. Your doctor needs to call the Express Scripts Prior Authorization department to find out if this drug can be covered by your plan. Only your doctor (or in some cases, your pharmacist) can provide the information needed to make this determination.
6. Does this program deny me the medicine I need?
No, the program can help you get an effective medicine to treat your condition. Through Prior Authorization, you can receive the right prescription drug for you that is covered by your benefits.
If it’s determined that your plan doesn’t cover the medicine you were prescribed, you can ask your doctor about getting another drug that is covered. You’ll receive it for your plan’s copayment. Or, you can get the original prescription filled at your pharmacy by paying the full price.
7. What happens if my doctor’s request for prior authorization is denied?
Your pharmacy benefit plan doesn’t cover certain drugs. If you want to file an appeal to have your prescription drug covered, call or write to the Fund Administrator for more information or contact Express Scripts at the number on the back of your prescription card.
8. I filed an appeal and it was denied. What can I do?
There are two things you can do:
·You can talk with your doctor again about prescribing one of the drugs that are covered by your plan. Your copayment will usually be affordable for one of these drugs.
·OR you can pay the full price of a drug that isn’t covered by your plan.
Mail Service and Prior Authorization
9. I sent in a prescription for mail-order delivery, but I was contacted and told it needs a prior authorization. What happens now?
The Express Scripts Mail Service Pharmacy will try to contact your doctor. You may want to call your doctor to let him/her know that this call will be coming. If your doctor thinks you need this drug for your condition, he/she can talk with the Mail Service Pharmacy representative about a prior authorization.
