Members must get prior authorization for certain medications, which must be renewed periodically. Some of these medications may be covered with limits, provided that you receive approval through a coverage review. Examples of drug categories requiring prior authorization include, but are not limited to, growth hormones, interferons, erythroid stimulants and oncologic agents. During this review, Express Scripts will ask your doctor for more information than what is on the prescription before the medication may be covered under the Plan.
This extra screening protects you or your family members by making sure the medication is safe for you and prescribed at the right dosage. Prior authorization helps you avoid taking a medication that could have adverse effects on your health. It also reduces costs associated with inappropriate medication use.
Additional examples of when prior authorization may be required:
- Medications with age or gender limitations
- Medications prescribed for a quantity exceeding normal limits
- A more effective alternative may exist
If your prescription needs prior authorization, your pharmacist will make a request to your provider. Only your provider can submit this information.
If you submit a prescription for a medication that has quantity limits, your pharmacist can dispense up to the allowable amount. Approval is needed before additional quantities can be filled. Unless your doctor obtains approval, you will be responsible for the cost of the medication that exceeds the quantity allowed by your Plan. Express Scripts will notify you and your doctor of the decision.
To find out what drugs require prior authorization or have quantity limits, call Express Scripts’ prior authorization number (800) 753-2851.