Accredo is the specialty pharmacy arm of Express Scripts. As of January 1, 2021, we switched pharmacy benefit managers (PBM) from Optum to Southern Scripts. The step therapy approach may utilize automated adjudication logic that reviews a patient's past prescription claims history to qualify a patient for coverage at the point-of-sale without requiring the prescriber to complete the administrative prior authorization review process.
Southern Scripts only charges an "administrative fee" to provide their service and don't apply any hidden fees like other PBMs. Tips to keep in mind Go to to locate an in-network pharmacy. A Tool to Promote Appropriate Drug Use and to Prevent Misuse: Prior authorization can be used for medications that have a high potential for misuse or inappropriate use. For example, to protect against cardiovascular disease, a patient may need significant reductions in LDL (bad) cholesterol levels that may not be achievable with a health plan's formulary drug and therefore a coverage exception for a high-potency non-formulary medication would be requested using the plan's exception process provided certain circumstances are met to ensure patient safety and appropriate utilization. Customer Service: 800-552-6694Monday – Friday: 8 a. Southern scripts prior auth form pdf. m. -8 turday: 11 a. Select your plan to receive the appropriate assistance from our support team.
For example, a step therapy approach may be used for non-steroidal anti-inflammatory drugs (NSAIDs), a drug class that is used to treat conditions such as arthritis pain and inflammation. Save Cash on Prescriptions by Understanding How Your Benefits Work. Health plans, employers and government-sponsored health care programs are focusing their attention on optimizing patient outcomes through the use of medications that have established evidence of efficacy and safety, while providing the highest value. A newer, more expensive branded NSAID also treats pain and inflammation, but may be a better option for patients who have experienced a gastrointestinal side effect with a traditional NSAID or who already have a gastrointestinal condition. A 90-day supply is available through mail order. An NSAID step therapy rule requires that a patient try a traditional, generic NSAID or provide documentation of a gastrointestinal condition prior to receiving approval to fill a prescription for the newer, more expensive branded product. » Or you can visit Express Scripts online at to order prescription refills, check order status, locate participating retail pharmacies, find ways to save money on your medications through generics and mail order, and ask a pharmacist questions 24/7. If you experience an issue, call the Southern Scripts number (800-710-9341) on the front of your insurance card. A prior authorization request for an off-label indication requires documentation from the prescriber to confirm the use for which the product was prescribed. Southern scripts prior auth form for medications. Traditional NSAIDs are available in generic forms and offer an established option for treating pain and inflammation, but they can sometimes result in stomach irritation and side effects. Or fill out the form below, and we'll be in touch! The Academy of Managed Care Pharmacy's mission is to empower its members to serve society by using sound medication management principles and strategies to achieve positive patient outcomes. Utilizing manufacturer coupons, the Variable Copay™ program is designed to bring members savings on specialty drugs. The prior authorization process will ensure that coverage for these select medications will be granted when medically necessary and prescribed by the appropriate specialist (e. g. limiting the prescribing of chemotherapy medications to oncologists.
Prior authorization procedures and requirements for coverage are based on clinical need and therapeutic rationale. Download our Southern Scripts Quick Sheet to learn more. Most ulcers are healed within an eight-week duration of therapy; therefore, plans may limit the duration of treatment to minimize side effects and reduce inappropriate long-term use. Certain conditions, such as erosive esophagitis, however, may require chronic administration of proton pump inhibitors. We're ready to discuss your PA and full-service BPO needs. Track prescriptions and home delivery refills. This list may change, please contact Express Scripts for the most up to date information).
And the good news is you can access both Express Scripts and Accredo from the Express Scripts mobile app. 2 Administration of a prior authorization process must take into consideration the desired outcome for the patient, the design of the drug benefit, the value to the plan sponsor, and all statutory and regulatory requirements. The prior authorization process can be used to obtain this additional information. Prior authorization requires the prescriber to receive pre-approval for prescribing a particular drug in order for that medication to qualify for coverage under the terms of the pharmacy benefit plan. Prior Authorization Addresses the Need for Additional Clinical Patient Information: The prior authorization process can address the need to obtain additional clinical patient information. The prior authorization process can be used by prescribers and patients to request coverage for drugs that are not included on a plan's formulary. They can identify and resolve the issue for you in real time. For example, a patient's clinical diagnosis, weight and height information, laboratory results, over-the-counter medication use, and non-drug therapy are examples of information that is not transmitted during the claims adjudication process.
Specialty prescriptions are also available as a 30-day supply through mail order. We know that when it comes to pharmacy benefit management, transparency is key. Ready to learn more? The plan may require the prescriber to present evidence supporting the unapproved use or assign a pharmacist to conduct a medical literature review to search for evidence for that indication. For example, Botox is used to treat muscular disorders, but can also be used for cosmetic purposes (e. g., eliminate wrinkles).
As no formulary can account for every unique patient need or therapeutic eventuality, formulary systems frequently employ prior authorizations. 2023 Preferred/Formulary Drug List *Not all drugs listed are covered by all prescription plans. 4 Academy of Managed Care Pharmacy. The co-insurance is 15% of the cost of the drug.
A Transformative Pharmacy Benefit Management Solution. The $10 penalty will not accumulate toward the deductible or maximum out-of-pocket limit. If the plan does not cover cosmetic products or procedures, the prior authorization program would ensure that Botox is covered only when it used for appropriate medical indications. If your health benefits count prescription costs toward a deductible: Exception Process for Closed Formulary Benefits: The formulary is a key component of health care management and is a tool used to ensure that the medications available for use in a prescription drug program have been demonstrated to be safe, effective and affordable while maintaining or improving the quality of patient care. Drug list for medications that qualify for the Smart90 program.
If your doctor prescribes a specialty medication, that is covered, too. Refill and renew prescriptions. If patients have the first-line drug in their claims history, they may automatically qualify for coverage of a second-line therapy without triggering a review for coverage. Maintenance drugs filled at a retail pharmacy (other than Walgreens) will include a $10 penalty after the second retail fill. Easy & Cost Effective. Under an open formulary pharmacy benefit, the health plan or payer provides coverage at the point-of-sale for all medications covered under the prescription benefit, even those not listed on the formulary. This pass-through and transparent PBM offers innovative solutions that generate meaningful savings for employers. By employing the prior authorization process, plans can extend the duration of the therapy limit for patients who meet established parameters. Phone: (866) 205-5107.
The role of pharmacy benefit managers is to determine which medications are covered on the prescription drug list and work with pharmacies on dispensing the medications covered on your plan. 2023 Excluded Medication List - NOT COVERED. Your GuideStone® medical plan utilizes Express Scripts® as our pharmacy benefit manager. Prior authorization may also be referred to as "coverage determination, " as under Medicare Part D. Guidelines and administrative policies for prior authorization are developed by pharmacists and other qualified health professionals Each managed care organization develops guidelines and coverage criteria that are most appropriate for their specific patient population and makes its own decisions about how they are implemented and used. Fax: (833) 774-9246. Combat High-Cost Specialty Medications with Variable Copay™. 2 Robert Navarro, Michael Dillon and James Grzegorczyk, "Role of Drug Formularies in Managed Care Organizations, " in Managed Care Pharmacy Practice, ed. Retail and mail services on the medical programs are administered through Express Scripts. In addition, this type of logic may use other available patient data (e. g., age, gender, concomitant medications, diagnosis, and physician specialty) to qualify patients for coverage without the need for a prior authorization review. Requiring prior authorization in a drug benefit can effectively help avoid inappropriate drug use and promote the use of evidence-based drug therapy. In this case there is insufficient clinical evidence supporting the use of the medication for non-cancer purposes and prescribing such a medication could pose a serious safety risk for the patient. Enter your information — be sure to have your member ID number ready — and create a login. Check the status of a prior authorization, review your drug list and enroll in the variable copay program from the app. This information is then evaluated against established plan coverage guidelines to determine if coverage is appropriate.
Copay changes to maximum amount from manufacturer. Well-designed prior authorization programs consider the workflow impact on health care system users and minimize inconvenience for patients and providers.
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