What is prescription drug coverage?

Prescription Drug Coverage. Health insurance or plan that helps pay for prescription drugs and
medications.

What is the purpose of drug coverage?

Is to help with the cost of medications.

What are the benefits of having drug coverage?

It helps the insured member pay less.

What is a PRIOR AUTHORIZATION?

-requirement from your health insurance company that your doctor obtain approval from your
plan before it will cover the costs of a specific medicine, medical device or procedure;

What is the purpose of a PRIOR AUTHORIZATION?

-Prior authorization ensures that you get the prescription drug that is right for you and that is
covered by your benefit. If it's determined that your plan doesn't cover the drug you were
prescribed, you can ask your doctor about getting another prescription that is covered.

-Prior authorization can help lower the cost of expensive prescriptions by first requiring you to try
a lower cost alternative that’s equally effective. The process also allows your health insurance
company to review your prescriptions, looking for any potentially dangerous drug interactions
that your doctor may have been unaware of when prescribing

-insurance company a chance to review how necessary a certain medication may be in treating
your medical condition. For example, some brand name medications are very costly. During
their review the insurance company may decide a generic or another lower cost alternative may
work equally well in treating your medical condition. Other types of medications are dangerous
when combined with others you may already be taking, others are very addictive, etc.

What drugs may require a PRIOR AUTHORIZATION?

-Brand name medicines that are available in a generic form

-Expensive medicines, such as those needed for psoriasis or rheumatoid arthritis

-Drugs used for cosmetic reasons. For example, medications that are prescribed to re-grow hair
or to prevent hair loss, or medications used to treat facial wrinkling

-Drugs prescribed to treat a non-life threatening medical condition, such as erectile dysfunction
drugs

-Drugs not usually covered by the insurance company, but said to be medically necessary by
the prescriber. Many different drugs can be used to treat the same condition. If a patient
requires a particular medicine, the doctor must inform the insurance company that there are no
other medicines that would be effective for the patient.

-Drugs that are usually covered by the insurance company but are being used at doses higher
than normal.

COVERAGE REVIEW:
-During a coverage review, Express Scripts contacts your doctor for more information before the
medication will be covered under your plan.

-If you know in advance that your prescription requires a coverage review, ask your doctor to
call the coverage review team before you go to the
pharmacy. This call will initiate a review, which typically takes one to two business days. Once
the review is complete, Express Scripts will send a letter to notify you and your doctor of its
decision. If the review is approved, the letter will tell you the length of your coverage approval. If
coverage is denied, the letter will include the reason for coverage denial and instructions on how
to submit an appeal.

THINGS YOU CAN DO ON EXPRESS-SCRIPTS WEBSITE/MOBILE APP:

• Order refills and renewals
• Check order status
• Transfer medicines to home delivery
• Compare pricing and coverage for brand-name and generic medicines
• Find participating retail pharmacies and compare pharmacy prices
• Find detailed drug information
•Pay Bill/Check Balance
•Review prescription history and expenses
•Get Prior Author forms