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Effective July 1, 2022: Express Scripts Advanced Utilization Management Program. If you experience an issue, call the Southern Scripts number (800-710-9341) on the front of your insurance card. 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. This information can be requested by contacting the Customer Service Department. Southern scripts prior auth form 2021. 2023 Preferred/Formulary Drug List *Not all drugs listed are covered by all prescription plans. Under an open formulary pharmacy benefit, the health plan or payer provides coverage at the point-of-sale for all medications covered under the prescription benefit, even those not listed on the formulary. A Transformative Pharmacy Benefit Management Solution.
As of January 1, 2021, we switched pharmacy benefit managers (PBM) from Optum to Southern Scripts. In some instances, members receive their medication for as low as $.
Requiring prior authorization in a drug benefit can effectively help avoid inappropriate drug use and promote the use of evidence-based drug therapy. Maintenance drugs filled at a retail pharmacy (other than Walgreens) will include a $10 penalty after the second retail fill. Southern scripts prior auth form authorization form. 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. Traditional NSAIDs are available in generic forms and offer an established option for treating pain and inflammation, but they can sometimes result in stomach irritation and side effects.
Show the pharmacy your new card when getting a prescription. Register From Your Computer: Go to. Administration of Quantity Management Rules: The prior authorization process can be used to administer quantity management rules, including rules based on duration of therapy, quantity over a period of time and maximum daily dose edits. 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. 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. A plan may limit drug benefit coverage to quantities that are consistent with FDA-approved durations or dosing. Prescriptions - Express Scripts | Village of Hoffman Estates. A prior authorization request for an off-label indication requires documentation from the prescriber to confirm the use for which the product was prescribed. We have three types of pharmacy programs with SouthernScripts that save money on prescriptions: NOTE: Walgreens and Costco can only dispense 1 month medication supplies. This type of prior authorization requirement is appropriate for specialized medications that require a high level of expertise in prescribing and monitoring treatment. 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.
A pharmacist would then evaluate the documentation to determine whether use of the prescribed drug for the indication provided is justifiable. 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. Phone: (855) 742-2054. A newer, more expensive branded NSAID also treats pain and inflammation, but may be a better option for patients who have experienced a gastrointestinal side effect with a traditional NSAID or who already have a gastrointestinal condition. 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. Concepts in Managed Care Pharmacy Series -- Formulary Management. The Academy of Managed Care Pharmacy (AMCP) recognizes the role of prior authorization in the provision of quality, cost-effective prescription drug benefits. Administration of Step Therapy: Another prior authorization approach is step therapy. Tips to keep in mind Go to to locate an in-network pharmacy. Specialty prescriptions are also available as a 30-day supply through mail order. A 90-day supply is available through mail order. The prior authorization process will ensure that coverage for these select medications will be granted when medically necessary and prescribed by the appropriate specialist (e. g. limiting the prescribing of chemotherapy medications to oncologists.
» Express Scripts customer service representatives can be reached at 800. 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. 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. The process gives the prescriber the opportunity to justify the therapeutic basis for the prescribed medication. 0917 24 hours a day, 7 days a week. Prior authorization guidelines may stipulate that only certain medical specialists may prescribe a given medication. Accessed March 28, 2012).
For example, to protect against cardiovascular disease, a patient may need significant reductions in LDL (bad) cholesterol levels that may not be achievable with a health plan's formulary drug and therefore a coverage exception for a high-potency non-formulary medication would be requested using the plan's exception process provided certain circumstances are met to ensure patient safety and appropriate utilization. For example, proton pump inhibitors are effective in treating peptic ulcer disease. Or fill out the form below, and we'll be in touch! Utilization of this logic allows plans to manage the benefit without requiring unnecessary member or prescriber disruption. The $10 penalty will not accumulate toward the deductible or maximum out-of-pocket limit. The role of pharmacy benefit managers is to determine which medications are covered on the prescription drug list and work with pharmacies on dispensing the medications covered on your plan. This list may change, please contact Express Scripts for the most up to date information). This process provides a mechanism to provide coverage on a case-by-case basis for medications otherwise not eligible for coverage. For example, Botox is used to treat muscular disorders, but can also be used for cosmetic purposes (e. g., eliminate wrinkles). For specific questions about your coverage, call the phone number listed on your member card.
Well-designed prior authorization programs consider the workflow impact on health care system users and minimize inconvenience for patients and providers. 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! An NSAID step therapy rule requires that a patient try a traditional, generic NSAID or provide documentation of a gastrointestinal condition prior to receiving approval to fill a prescription for the newer, more expensive branded product. 2023 Excluded Medication List - NOT COVERED. A step therapy approach to care requires the use of a clinically recognized first-line drug before approval of a more complex and often more expensive medication where the safety, effectiveness and value has not been well established, before a second-line drug is authorized. Customer Service: 800-552-6694Monday – Friday: 8 a. m. -8 turday: 11 a. Prior authorization (PA) is an essential tool that is used to ensure that drug benefits are administered as designed and that plan members receive the medication therapy that is safe, effective for their condition, and provides the greatest value. 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. In most cases, a PBM can resolve the problem by reaching out to the pharmacy on your behalf. Prior authorization would be used to limit coverage in this situation to those patients where safety and appropriate use has been documented.
The prior authorization process can be used to obtain this additional information. All-Inclusive Administration FeeNo additional fees for standard PBM services, such as prior authorizations, step therapy, and data reporting. FirstChoice™ Pharmacy Network. Mail order prescriptions delivered in private, secure packaging. Phone: (855) 225-3997. PA Logic distributes the specific clinical criteria used for clinical decisions upon request. Phone: (866) 689-0493. Southern Scrips applies an innovative PBM model that can help improve the member experience, lower cost, and enhance the quality of care. To view the prescription drug list, go to then scroll down and enter the name of your medications to determine which prescription drug tier it is in. 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. Independent (local/community) and retail (national/regional) pharmacies.