These are programs your doctor MUST use:
- Prior Authorization. Your doctor must request approval for all Specialty and Biosimilar drugs and some Preferred and Non-Preferred Brand Name drugs before the prescription is picked up. If you need to take a drug that requires prior authorization, your doctor must call (844) 813-3860.
- Step Therapy. Before using some drugs that are very expensive, you and your doctor must try less expensive drugs that are proven to work just as well—sometimes they even have the same ingredients.
- Quantity Limit Program. This is sometimes called “dispensing limits.”There are certain prescription drugs that many providers prescribe at higher dosages than the FDA considers to be safe. Coverage for these prescription drugs will be limited to a 30-day supply.
These programs save you and your health fund money, keep you safe, and prevent abuse and fraud.
We know it is sometimes medically necessary to take a drug even if it is the more expensive option. In these situations, your doctor must get approval by calling (844) 813-3860.
Medications may be added to the Step Therapy and prior authorization lists throughout the year. If your prescription is ever affected by this, we will notify you before the change.
These include drugs used to treat health conditions such as growth hormone deficiency, hepatitis C, immune deficiency, hemophilia, multiple sclerosis and rheumatoid arthritis.
- We work with Optum Specialty Pharmacy to get the best service and the best prices. If you need a specialty drug, you MUST get them through this specialty pharmacy. Your doctor MUST first get approval by calling: (844) 813-3860
- We will help you with this transition process. If you are currently taking a Specialty drug, have your doctor call us at (844) 857-5772 to learn how to transition to Optum Specialty Pharmacy.
- Because of an exciting new program we are using, you may pay less some months for your Specialty drugs than the listed maximum copay—we will provide details when we contact you.