Preauthorization
You or your prescribing physician can find out if preauthorization is required by contacting Express Scripts before you have a prescription filled.
Express Scripts doesn't determine the maximum number of refills or period when a prescription is valid because these requirements are mandated by federal and state laws regulating pharmacy practices. To promote proper use of medications, preauthorization and quantity level limits have been implemented for certain prescriptions under your KingCareSM pharmacy benefit.
You or your prescribing physician can find out if preauthorization is required by contacting Express Scripts before you have a prescription filled. For you and your physician's convenience, Express Scripts customer service assistance is available 24 hours a day, 7 days a week at 1-800-417-8164. Otherwise, your pharmacist or the Express Scripts mail-order service will advise you of the preauthorization procedures required to fill the prescription.
Express Scripts routinely reviews prescribing guidelines to ensure that drugs are clinically appropriate, and may limit the quantities of certain drugs to ensure proper utilization. The list of drugs requiring preauthorization is subject to change. (For the most current list of these drugs, go to the Express Scripts Web site. See Contact Information.)
To preauthorize a prescription, your prescribing physician or his/her representative must initiate the process with a phone call to Express Scripts. Information required to complete the review includes but isn't limited to:
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member name;
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member ID number (located on your Express Scripts prescription drug card);
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birth date;
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name of drug;
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quantity and days' supply;
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diagnosis;
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previous therapies utilized; and
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prescribing physician information.
During the course of the review process, your eligibility will be confirmed and your prescription records checked to see if the prescription meets the established criteria.
Preauthorization requests are evaluated using criteria approved by KingCareSM. The request is then approved, denied or held for further information. If more information is required, Express Scripts will notify the requestor. Once the information is provided to your physician, your request will be approved or denied.
If the request is approved, Express Scripts will notify your physician and immediately update its database so you can fill the prescription.
If the request is denied, an Express Scripts clinical pharmacist will verify that the denial is valid according to plan criteria; Express Scripts will then notify:
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your physician verbally if the request was received by phone call; or
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you and your physician in writing if the request was received by mail.
When you receive a written denial, you may appeal that decision.
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