Answers to Common Questions

Prior Authorization

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.