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Prior Authorization What You Need to Know Q. What is prior authorization? A. Prior authorization is a clinical program that only applies to certain types of prescription medications. Prescription medications subject to the prior authorization program will require pre-approval before they can qualify for coverage under the pharmacy benefit plan. Q. Why does my prescription benefit include prior authorization? A. Prior authorization programs are commonly used to help encourage the appropriate use of medications. Review and pre-approval of a select group of drugs can also help to reduce the chances of unnecessary drug treatment and help contain overall health care costs. Q. How will prior authorization affect me? A. The vast majority of medications covered under your pharmacy benefit are not subject to a prior authorization program. Depending upon your specific benefit plan, a prior authorization program may be in effect for one or more prescription drugs. Call the Customer Service number on the back of your ID card for more details. If you or a family member receive a new prescription for a drug that is subject to the prior authorization program, your physician will need to submit an authorization request form. The easiest way for your physician to obtain the necessary form is by visiting our Web site at www.bcbstx.com. Forms and more detailed program information can be found in the Provider section. When possible, ask your physician to obtain a confirmed authorization before you take your prescription to the pharmacy to be filled. If a prescription is presented to the pharmacist before an approval has been placed into the system, your pharmacist will advise you to contact your doctor. The pharmacist will provide a toll-free number for your physician to call to obtain additional information. If you or a family member have a current prescription for a drug that has recently been added to the prior authorization program, in most instances, your physician will need to submit an authorization request form as described above. Review and pre-approval of a select group of drugs can help to reduce the chances of unnecessary drug treatment and help contain overall health care costs.

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Page 1: Prior Authorization What You Need to Know...If you or a family member receive a new prescription for a drug that is subject to the prior authorization program, your physician will

Prior Authorization What You Need to Know

Q. What is prior authorization?

A. Prior authorization is a clinical program that only applies to certain types of prescription medications. Prescription medications subject to the prior authorization program will require pre-approval before they can qualify for coverage under the pharmacy benefit plan.

Q. Why does my prescription benefit include prior authorization?

A. Prior authorization programs are commonly used to help encourage the appropriate use of medications. Review and pre-approval of a select group of drugs can also help to reduce the chances of unnecessary drug treatment and help contain overall health care costs.

Q. How will prior authorization affect me? A. The vast majority of medications covered under your pharmacy benefit are not subject to a prior authorization program. Depending upon your specific benefit plan, a prior authorization program may be in effect for one or more prescription drugs. Call the Customer Service number on the back of your ID card for more details.

If you or a family member receive a new prescription for a drug that is subject to the prior authorization program, your physician will need to submit an authorization request form. The easiest way for your physician to obtain the necessary form is by visiting our Web site at www.bcbstx.com. Forms and more detailed program information can be found in the Provider section. When possible, ask your physician to obtain a confirmed authorization before you take your prescription to the pharmacy to be filled. If a prescription is presented to the pharmacist before an approval has been placed into the system, your pharmacist will advise you to contact your doctor. The pharmacist will provide a toll-free number for your physician to call to obtain additional information.

If you or a family member have a current prescription for a drug that has recently been added to the prior authorization program, in most instances, your physician will need to submit an authorization request form as described above.

Review and pre-approval of a select group of drugs can help to reduce the chances of unnecessary drug treatment and help contain overall health care costs.

Page 2: Prior Authorization What You Need to Know...If you or a family member receive a new prescription for a drug that is subject to the prior authorization program, your physician will

Prior Authorization What You Need to Know

Q. How does the program work?

If the prior authorization request is approved:You will pay the appropriate amount based on your prescription drug benefit when you fill your prescription.

If the prior authorization request is not approved:The medication will not be covered under your prescription drug benefit. You can still purchase the medication, but you will be responsible for the full cost. Or, you can talk to your doctor to find out if another drug might be right for you. Your course of treatment can only be determined by you and your doctor. As always, the appeal rights provided by your benefit plan are available to you.

Q. How are the medications subject to prior authorization determined?

A. A team of physicians and pharmacists reviews categories of medications that are potentially over-prescribed, frequently very expensive and that require regular monitoring to assure good results. The team takes into consideration the U.S. Food and Drug Administration’s (FDA) prescribing information, as well as nationally recognized clinical guidelines written by experts in the specialties that apply.

Q. What types of medications are included in the prior authorization program?

A. Examples of drug categories that may be included in the prior

authorization program and sample medications include†*:• Growth hormones: Genotropin, Humatrope, Norditropin,

Nutropin AQ, Omnitrope, Saizen, Serostim, Tev-Tropin, Zorbtive• Hepatitis C medications: Infergen, PegIntron, Pegasys• Oral Fentanyl: Actiq, Fentora, Onsolis

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association 52736.0210

†Additional categories may be added and the program may change from time to time.*Third-party brand names are the property of their respective owners.

www.bcbstx.com/weatherford

The vast majority of medications covered under your pharmacy benefit are not subject to a prior authorization program.


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