Coverage management will be managed by Express Scripts. There is nothing required of the participant as the program will automatically be implemented when certain medications are prescribed. If a prescription requires coverage management, the prescribing physician will be consulted to provide additional information before the medication can be filled through the benefit plan.
- Prior authorization monitors prescription drugs to ensure participants are getting the medications that are suitable for their intended use and the patient has met certain criteria, such as age, sex, or condition necessary to ensure the effectiveness of the medication.
- Step therapy is a managed approach to prescription drugs intended to control costs and mitigate risks posed by certain medications. A review process is followed to make sure participants have tried other, lower first level medications that could work and determines if an alternate therapy course or treatment is appropriate.
- Quantity limitations promote the safe and appropriate use of medications intended for a limited duration of use and minimize potential waste of expensive medications. These quantity restrictions are based on product labeling or clinical guidelines and are subject to periodic review and change.