Coverage reviews (Prior authorization)

A coverage review (also called prior authorization) simply means that more information is needed to see if your plan covers a medication. This review makes sure you’re getting a medication that is prescribed for its intended use and covered by your pharmacy benefit.

Express Scripts works with doctors and pharmacists to determine which newly approved and existing medications are effective. Your plan uses this information to determine which medications are covered.

After Express Scripts receives a prior authorization request, then a review begins. Only your doctor can provide the necessary information for a coverage review. The review can be approved, denied or withdrawn.

You can check the status of a coverage review by logging in and going to Prior Authorizations under Prescriptions.

To help avoid a coverage review, ask your doctor if they’re connected to Real-Time Prescription Benefit; so they can check if your medication is covered by your plan before you try to fill it. You can also use your online account or our mobile app to check pricing and coverage.

We want to make sure you get the safest, most effective medication available. That means your prescription may require a review before it is covered by your plan. During the review, your doctor can provide us with more detailed information about your prescription so we can make sure its use falls within your plan’s rules. These rules are based on the product information approved by the Food and Drug Administration (FDA) as well as published clinical trials and guidelines.

Your medication may also need a coverage review if it is a:

• Prescription used outside of the specific, approved medical conditions
• Prescription that could be used for non-medical purposes

To help avoid a coverage review, ask your doctor if they’re connected to Real-Time Prescription Benefit so they can check if your medication is covered by your plan before you try to fill it. You can also use your online account or our mobile app to check pricing and coverage.

You can check the status of a coverage review by logging in and going to Prior Authorizations under Prescriptions.

If a coverage review is required, your pharmacy will receive an alert. This means that more information is needed from your doctor to see if your plan covers the medication.

Ask your doctor to either call Express Scripts to request a coverage review or to prescribe an alternative medication that’s covered by your plan. After Express Scripts receives a prior authorization request, then a review begins. Only your doctor can provide the necessary information for a coverage review.

You can track the status of your coverage review and get helpful information about the process online or through our mobile app. Log in and go to Prior Authorizations under Prescriptions.

If you receive coverage approval, your prescription will be filled like normal. If coverage is not approved and you don’t want an alternative medication, you have the option to pay full price for the prescription.

To help avoid a coverage review, ask your doctor if they’re connected to Real-Time Prescription Benefit so they can check if your medication is covered by your plan before you try to fill it. You can also use your online account or our mobile app to check pricing and coverage.

If you ordered a prescription through home delivery and a coverage review is needed, Express Scripts Pharmacy will try to contact your doctor.

To save time, you may want to let your doctor know that Express Scripts will be contacting them. If your doctor thinks you need this specific medication for your condition, they can contact Express Scripts to request a coverage review.

You can track the status of your coverage review and get helpful information about the process online or through our mobile app. Log in and go to Prior Authorizations under Prescriptions.

To help avoid a coverage review, ask your doctor if they’re connected to Real-Time Prescription Benefit so they can check if your medication is covered by your plan before you try to fill it. You can also use your online account or our mobile app to check pricing and coverage.

Nearly all coverage reviews are completed within two days of us receiving complete information from your doctor. Many are completed even sooner. Doctors using electronic prior authorization systems can receive coverage determinations within minutes.

If your prescription requires a coverage review but you need your medication quickly, you can:

• Talk with your pharmacist about filling a small supply of your prescription right away. You may have to pay full price for this medication.
• Ask your doctor to contact Express Scripts to request a coverage review. Only your doctor (or in some cases, your pharmacist) can provide the information needed. If your doctor feels the situation is urgent, faster processing can be requested.
• Ask your doctor about prescribing a covered alternative medication.
• You can fill the original prescription at full price.

To help avoid a coverage review, ask your doctor if they’re connected to Real-Time Prescription Benefit so they can check if your medication is covered by your plan before you try to fill it. You can also use your online account or our mobile app to check pricing and coverage.

If you don’t receive a coverage approval, you can:

• Talk to your doctor about getting an alternative medication that is covered by your plan. Before prescribing a medication, your doctor can use Real-Time Prescription Benefit to check if a medication is covered and help avoid a coverage review.
• You can file an appeal to have your medication covered. Your appeal rights and the process for filing an appeal will be explained in the coverage review denial letter or communication. You can call the number on your prescription ID card if you need help or more information.
• You can get the original prescription filled at your pharmacy by paying the full price.

You may need a new coverage review (prior authorization) because your previous approval expired, or your plan may have changed. To determine if a medication qualifies for ongoing coverage, we need to make sure we have up-to-date information.

If you are still taking this medication, ask your doctor to contact Express Scripts and provide the information needed for a coverage review. We will contact you and your doctor when the coverage review is complete.

If coverage is approved before the expiration date, your plan will continue to cover this medication without interruption. If coverage is not approved, you will be responsible for the full cost of the medication if you continue to fill it. You can also talk to your doctor about alternative medications that may be covered by your plan.