What is the Prior Authorization Program?

December 19, 2018

Your benefits plan is designed to provide you and your family with financial protection for a variety of medical expenses, including prescription drugs. The Prior Authorization Program helps to manage drug costs while continuing to provide you with access to appropriate drug therapy. The program validates that the drug is prescribed for its intended use and meets the terms and conditions outlined in your benefits booklet.

For a specific list of drugs, additional medical information is needed before determining if the drug is eligible. A drug may be prescribed to treat different medical conditions; one condition that may be covered under your benefits plan and one that may not be.

NOTE: The list of drugs requiring prior authorization is updated regularly, so be sure to check it each time you receive a new prescription.

Here are some helpful hints to keep in mind the next time you visit your doctor or pharmacist or prescribed a drug:

When your doctor prescribes a new drug:
  • Tell them that prior authorization may be required for certain drugs.
  • Access My drug plan to determine if the new drug is available as a generic and/or requires prior authorization.
  • Share the list of drugs requiring prior authorization (found in My drug plan on My Claims).
  • Tell them about the other drugs that you are currently taking to discuss if there may be any adverse reaction or side-effects when taking them together.
  • Make them aware of any drug allergies or reactions you’ve experienced in the past.
  • If the drug requires prior authorization, email the Drug Prior Authorization form to your doctor to complete the appropriate sections of the form. Then, you complete the rest of the form and print and send it to the address on the form or use the Send documents function on the My Claims home page.
When you pick up your prescription from the pharmacist:
  • Make sure you understand the instructions on how to take your
    medication.
  • Ask about possible side-effects and what to do if you experience them.
Other consideration
  • Wear a medical ID bracelet or necklace, if you have a medical condition and/or a drug allergy.

Use My drug plan to look for generic drug options

My drug plan is a user-friendly, drug lookup tool (found in My Claims quick links). It can help you to manage your drug costs especially because you have a mandatory generic drug plan. You can find out if a generic drug is available or if prior authorization is needed. A drug library is also right at your fingertips

IMPORTANT NOTES:

  • Drug costs seen in My drug plan are estimates only.
  • With a mandatory generic drug plan, any prescribed drug cost cannot exceed the price of the lower cost alternative drug, which is typically a “generic” drug.
    • If the drug you are prescribed is a “brand-name drug,” and there is no generic or interchangeable drug, your plan will reimburse you the cost of the brand name drug.
    • If there is a generic drug and you choose to buy the brand-name drug, your plan will reimburse you the cost of the generic drug.
    • In some instances, you may experience an adverse reaction to the generic drug, or it is therapeutically ineffective. When this happens, medical evidence can be submitted to support why the brand-name drug is being prescribed. To get approved for a brandname drug, you need to complete the Request for Approval of Brand-Name Drug form, have it signed by your doctor and return it to the address on the form. If approved, you will be paid back the cost of the brand-name drug.
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