Safe Prescribing Procedures
Your prescription drug benefit offers various procedures and safeguards to ensure that appropriate drugs and amounts are dispensed to our plan participants.
Prior authorization requires that providers receive approval from your pharmacy benefits management company before prescribing certain medications. This safeguard ensures that the drug prescribed is the most clinically appropriate for the participant at the lowest cost-sharing available. Prior authorization requirements on drugs new to the marketplace — until they can be clinically reviewed — provide time to identify potential safety issues. Prior authorization also ensures that drugs prescribed for off-label use are done so in accordance with the U.S. Food and Drug Administration (FDA) guidelines.
Clinical pharmacists evaluate requests for these drugs based on clinical data and information submitted by the prescribing physician and available prescription drug history. The clinical pharmacists determine whether there are potential drug interactions or contraindications and whether dosing and length of therapy are appropriate prior to approving a request.
If the request cannot be approved by applying established clinical review criteria, a medical director will review the request. Without prior authorization, the plan participant’s prescription will not be covered at a retail or mail order pharmacy.
Age and Gender Limits
The FDA has established clinical guidelines that govern prescribing practices for some drugs. These rules are designed to prevent potential harm to patients for drugs that have demonstrated contraindications for patients of a certain age or gender. For example, some drugs are approved by the FDA only for individuals age 14 and older, such as ciprofloxacin, or prescribed only for females, such as prenatal vitamins. The pharmacist’s computer provides up-to-date information about FDA rules. If a prescription falls outside of the FDA guidelines, it will not be covered until prior authorization is obtained. Physicians may request preapproval of restricted medications when medically necessary.
Quantity Level Limits
Quantity level limits are designed to allow a sufficient supply of medication based on FDA-approved maximum daily doses and length of therapy of a particular drug. If the prescription exceeds the quantity limit, the pharmacist will fill for the allowed supply, and then the participant must follow up with his or her physician regarding future prescriptions. If the plan participant's therapy requires a larger daily dose of medication, the prescribing physician may request a quantity limit override by submitting supporting information to your pharmacy benefits management comp