Program Descriptions: Prior Authorization, Step Therapy and Drug Quantity Management

What is Prior Authorization?

Certain medications prescribed to you by your doctor may require a Prior Authorization.

Prior Authorization is a program that monitors prescription drugs to ensure you are getting a medication that is suitable for the intended use and covered by your pharmacy benefit. This is similar to healthcare plans that approve certain medical procedures.

How Prior Authorization Works

If your prescription requires a prior authorization, your physician needs to be consulted to provide additional information before it can be covered under your benefit. The pharmacist’s computer will have the phone number for Express Scripts who then will speak with your physician. Only your physician can provide this necessary information to insure the prescription is dispensed safely and for the appropriate conditions.

If your physician confirms that the clinical criteria are satisfied, the prescription can be filled under your benefit coverage. If the clinical criteria are not satisfied, the claim is not covered under your benefit. Express Scripts will contact your pharmacist and will also send you a letter describing the reasons for denial and to provide instructions if you wish to appeal this denial.

What is Step Therapy?

Certain medications prescribed to you by your doctor may require a Step Therapy. This program was put in place because within specific therapy classes, multiple drugs are available to treat the same condition and have very similar side effects. The costs for these drugs, however, can vary significantly. Physicians have reviewed these medications and determined, in most cases, they are interchangeable. The Step Therapy Program will help reduce costs to the plan and to patients. The Step Therapy Program will require that you try a clinically effective, lower-cost mediation (Step 1) before using a higher-cost medication (Step 2 medication). If a trial with the Step 1 medication was not appropriate for you, your physician can request approval to use a Step 2 medication.

How Step Therapy Works

The process for Step Therapy is very similar to the Prior Authorization process.

The first time you submit a prescription for a Step 2 medication, your pharmacist will inform you that an authorization is required. Your pharmacist’s computer will have the phone number for Express Scripts who will then speak with your physician. Only your physician can provide the necessary information regarding your experience with the Step 1 medications and to permit coverage of the Step 2 medication.

If your physician confirms that the Step 1 medication is not appropriate for you, the prescription for the Step 2 medication can be covered under your benefit. Examples why a Step 1 medication may not be appropriate for you include a previous unsuccessful trial or an allergy to the Step 1 medication. If the criteria are satisfied, Express Scripts will contact your pharmacist that your prescription has been approved. If the criteria is not satisfied, the claim is not covered under your benefit. Your physician may change the prescription to a Step 1 medication which is covered under your benefit. Your pharmacist will be contacted and will then fill the prescription with this approved medication. Similar to the prior authorization process, you can appeal the denial.

What Is Drug Quantity Management (DQM)?

Drug Quantity Management, also known as DQM, is a program designed to make your prescription drugs safer and more affordable. DQM does not deny access to the medication, it will only provide quantities according to the medical guidelines. DQM ensures that the doctor is prescribing your medication at a dose and quantity considered safe and effective according to guidelines from the U.S. Food & Drug Administration (FDA).

How Drug Quantity Management Works

When you submit your prescription, your pharmacist sees a message on the computer system indicating that the quantity is exceeding the maximum allowed. This message will also include quantity which would be covered under your benefit. The pharmacist can then dispense this quantity which is covered under your benefit. Similar to the prior authorization program, your physician can request an approval to dispense the original amount and strength he/she prescribed. If the reasons for a higher quantity meet the criteria, an approval is put into the computer system and you can receive the original quantity prescribed.