What does it mean when my prescription requires prior authorization?
If your prescription is not authorized, the pharmacy will attempt to contact the prescriber and/or patient to provide information about the claim rejection.
Some common reasons for claim rejection are:
Drug Specific Prior Authorization – This feature insures that drugs are being used for their designed purpose. If a prescription is presented for any of the following classifications of drugs, the prescriber must provide Express Scripts with documentation for review. Anabolic Steroids, Anti-Narcoleptic Agents, Cosmetics, Dermatological Agents, Erythroid Stimulants, Human Growth Hormone, Immunomodulatory Agents, Interferons, Misc. Hormones - Acthar H.P. Gel® (Specialty), Multiple Sclerosis Therapy, Myeloid Stimulants, Select Androgens, Specialty and Weight Loss Agents.
A Drug Utilization Review– is performed for certain medication which have specific uses and/or indications. This is designed to ensure that plan participants receive appropriate prescription medication therapy. A prescriber will submit a requet to Express Scripts to review a prescription that falls into this category. The Express Scripts’ determination is based on FDA-approved prescribing and safety information, clinical guidelines, and uses that are considered reasonable, safe, and effective.
Preferred Drug Step Therapy (PDST)– This feature requires that the patient try a generic alternative or preferred brand name medication before a higher cost non-preferred drug is used. This feature generally applies to the following drug categories: Angiotensin II Receptor Blockers (ARBs), Atypical antipsychotics (Abilify®, Saphris®, Invega®), Anti-Depressants, Celebrex®, CNS Stimulants & Amphetamines, Dermatologicals, Gastrointestinal, Intranasal Steroids, Migraine Medications, Osteoporosis, Pain Management (Fentora®, Onsolis®, Abstral®), Rheumatoid Arthritis, Synagis®, Pulmonary Arterial Hypertension, Rebetol®, Cobegus® and Sleep Medications.