What is the process for prior authorization?

The process for prior authorization with Express Scripts typically involves several key steps aimed at ensuring that certain medications are appropriate for a patient's specific condition and circumstances before they are dispensed. First, when a healthcare provider prescribes a medication that requires prior authorization, they may initiate the process by submitting a request to Express Scripts. This request usually includes details about the patient's medical condition, the prescribed medication, and any relevant clinical information that supports the need for that medication. Once the request is received, Express Scripts reviews it according to established criteria. These criteria may consider factors such as the effectiveness of the medication for the diagnosed condition, potential alternatives that may be covered without prior authorization, and any applicable clinical guidelines. If the request meets the necessary criteria, Express Scripts will issue an approval, allowing the medication to be covered under the patient's plan. In some cases, Express Scripts may require additional information from the healthcare provider or may deny the request if it does not meet the guidelines. In the event of a denial, the provider and patient are usually notified, and they may have the option to appeal the decision. This process is designed to ensure that patients receive the most appropriate and cost-effective care while also managing the pharmacy benefit effectively. For detailed information or specific inquiries regarding the prior authorization process, individuals may find it helpful to consult the relevant sections on the Express Scripts website, which provides current and comprehensive information.