A Tool to Promote Appropriate Drug Use and to Prevent Misuse: Prior authorization can be used for medications that have a high potential for misuse or inappropriate use. Phone: (855) 742-2054. This process provides a mechanism to provide coverage on a case-by-case basis for medications otherwise not eligible for coverage. This type of prior authorization requirement is appropriate for specialized medications that require a high level of expertise in prescribing and monitoring treatment. A pharmacist would then evaluate the documentation to determine whether use of the prescribed drug for the indication provided is justifiable. Southern Scripts, 2022.
Lowest Net-Cost ApproachSouthern Scripts' robust clinical management program and high-performance drug formularies deliver the lowest net cost to protect plans from unnecessary expenses. Independent (local/community) and retail (national/regional) pharmacies. Prior authorization requires the prescriber to receive pre-approval for prescribing a particular drug in order for that medication to qualify for coverage under the terms of the pharmacy benefit plan. This information is then evaluated against established plan coverage guidelines to determine if coverage is appropriate. Fax: (833) 774-9246. In addition, this type of logic may use other available patient data (e. g., age, gender, concomitant medications, diagnosis, and physician specialty) to qualify patients for coverage without the need for a prior authorization review. One major change in switching from Optum to Southern Scripts is that there are no minimums to prescription costs. The fundamental goal of prior authorization is to promote the appropriate use of medications. Fax: (844) 508-4690. The plan may require the prescriber to present evidence supporting the unapproved use or assign a pharmacist to conduct a medical literature review to search for evidence for that indication. This information can be requested by contacting the Customer Service Department. Requiring prior authorization in a drug benefit can effectively help avoid inappropriate drug use and promote the use of evidence-based drug therapy. Show the pharmacy your new card when getting a prescription. One-of-a-Kind PBM Model.
Robert Navarro, p. 249. Concept Series: What is Prior Authorization and Why is it an Essential Managed Care Tool? Express Scripts is the largest independent manager of pharmacy benefits in the United States and one of the country's largest pharmacies, serving more than 85 million people! FirstChoice™ Pharmacy Network. For example, Botox is used to treat muscular disorders, but can also be used for cosmetic purposes (e. g., eliminate wrinkles). AMCP has more than 4, 800 members nationally who provide comprehensive coverage and services to the more than 200 million Americans served by managed care. In this case there is insufficient clinical evidence supporting the use of the medication for non-cancer purposes and prescribing such a medication could pose a serious safety risk for the patient. Download our Southern Scripts Quick Sheet to learn more. For example, proton pump inhibitors are effective in treating peptic ulcer disease.
4 Academy of Managed Care Pharmacy. Pharmacists in all practice settings must develop specific guidelines to ensure that the prior authorization process is administered in the most efficient manner possible, is fully compliant with statutory and regulatory requirements, and provides members, prescribers and pharmacists with an evidence-based, rational process to promote appropriate drug use. For example, a patient's clinical diagnosis, weight and height information, laboratory results, over-the-counter medication use, and non-drug therapy are examples of information that is not transmitted during the claims adjudication process. » Express Scripts customer service representatives can be reached at 800. Health plans, employers and government-sponsored health care programs are focusing their attention on optimizing patient outcomes through the use of medications that have established evidence of efficacy and safety, while providing the highest value.
If patients have the first-line drug in their claims history, they may automatically qualify for coverage of a second-line therapy without triggering a review for coverage. If the cost of your prescription is less than the co-pay, no co-pay will be charged. We're ready to discuss your PA and full-service BPO needs. Under a closed formulary pharmacy benefit, the health plan or payer provides coverage at the point-of-sale only for those drugs listed on the formulary.
So, in the same way your medical plan provides for doctor's visits, your Express Scripts prescription plan provides an easy, cost-effective way to obtain the medication your doctor prescribes. 0917 24 hours a day, 7 days a week. The Academy of Managed Care Pharmacy's mission is to empower its members to serve society by using sound medication management principles and strategies to achieve positive patient outcomes. 2 Administration of a prior authorization process must take into consideration the desired outcome for the patient, the design of the drug benefit, the value to the plan sponsor, and all statutory and regulatory requirements.
Implementation of a well-designed, evidence-based prior authorization program optimizes patient outcomes by ensuring that patients receive the most appropriate medications while reducing waste, error and unnecessary prescription drug use and cost. 1 Drugs that require prior authorization will not be approved for payment until the conditions for approval of the drug are met and the prior authorization is entered into the system. "Prior Authorization Programs: A Critical Review of the Literature. " Fax: (833) 231-3647. Prior authorization would be used to limit coverage in this situation to those patients where safety and appropriate use has been documented. Most ulcers are healed within an eight-week duration of therapy; therefore, plans may limit the duration of treatment to minimize side effects and reduce inappropriate long-term use. Journal of Managed Care Pharmacy 7 (July/August 2001): 297. Select your plan to receive the appropriate assistance from our support team. For some categories, health plans may limit the coverage of drugs to FDA-approved uses and require a prior authorization for off-label indications. Phone: (855) 865-4688. Participating FirstChoice™ pharmacies offer, on average, a lower cost on medications for covered drugs than a standard (non-preferred) pharmacy. Prior authorization procedures and requirements for coverage are based on clinical need and therapeutic rationale.
For example, a step therapy approach may be used for non-steroidal anti-inflammatory drugs (NSAIDs), a drug class that is used to treat conditions such as arthritis pain and inflammation. Exception Process for Closed Formulary Benefits: The formulary is a key component of health care management and is a tool used to ensure that the medications available for use in a prescription drug program have been demonstrated to be safe, effective and affordable while maintaining or improving the quality of patient care. Prior Authorization Addresses the Need for Additional Clinical Patient Information: The prior authorization process can address the need to obtain additional clinical patient information. Retail and mail services on the medical programs are administered through Express Scripts. If your health benefits include a prescription co-pay: A 30-day supply of your prescription is available at a retail store. Southern Scrips applies an innovative PBM model that can help improve the member experience, lower cost, and enhance the quality of care. The step therapy approach may utilize automated adjudication logic that reviews a patient's past prescription claims history to qualify a patient for coverage at the point-of-sale without requiring the prescriber to complete the administrative prior authorization review process. Concepts in Managed Care Pharmacy Series -- Formulary Management. For example, online adjudication of prescription claims by prescription benefit management companies (PBMs) and health plans has resulted in an efficient process for administering the drug benefit, however necessary and pertinent information required for drug coverage decisions is not always available via the online adjudication system. Combat High-Cost Specialty Medications with Variable Copay™.
Copay changes to maximum amount from manufacturer. Sign up for home delivery. This list may change, please contact Express Scripts for the most up to date information). Look for the following images in your search to find the right pharmacy for you: The Human Resources Benefits Team is always here to answer your questions. Mail order prescriptions delivered in private, secure packaging. Save Cash on Prescriptions by Understanding How Your Benefits Work. Tips to keep in mind Go to to locate an in-network pharmacy. An example of an off-label use could be a physician prescribing a powerful opiate that has only been approved by the FDA to treat break-through cancer pain, in a patient that has chronic back pain. Phone: (866) 205-5107. Fax: (844) 580-3965. If the required therapeutic benefit is not achieved by use of the first-line drug, the prescriber may request use of a second-line medication.