Most of the time, you can take your prescription to the pharmacy and get it filled. But some drugs have special requirements that need to be met before your prescription is covered. We want to ensure members receive appropriate medication amounts and are using proven, cost effective drug therapies. Our clinical programs/edits help us monitor drug list compliance, clinical appropriateness, medication safety, refill frequency, dispensing limitations, and overall cost and quality consistency:
Prior Authorization: Prescriptions for certain drugs may require “prior authorization” from a health benefits plan before they can be filled. Some drugs require prior authorization because they may not be appropriate for every member or may cause side effects. Prior authorization helps promote appropriate utilization and enforcement guidelines of prescription drugs. Your doctor will request a prior authorization on your behalf.
Step Therapy: Step therapy involves requiring the usage of a drug, drug regimen, or treatment prior to the usage of another drug, drug regimen, or treatment. In instances in which a drug, drug regimen, or treatment is not effective and/or appropriate for a particular member, the step therapy requirements allow the doctor to then prescribe a different drug, drug regimen, or treatment.
Quantity Limits: Overuse of drugs can be unsafe for members. With quantity limits, members receive the drug amount that is approved for benefit coverage for a certain length of time, and coverage of a prescription is rejected if the amount prescribed exceeds recommended prescribing guidelines.