Drugs Requiring Approval

  • The Pharmacy Preapproval Program includes four types of reviews:

    • Drug list exception (nondrug list)
    • Quantity limit
    • Step therapy
    • Preapproval

    You can use our Rx Search tool to see if a drug falls into one or more of these categories.

    To request a review, the pharmacy or the provider must contact our Pharmacy services center at 888-261-1756 or fax a drug-specific online form (see Preapproval drugs section).

    Sometimes a pharmacy can do a one-time override for urgently needed medication.

    Learn more about emergency fills.

    Drug list exception review

    A drug list exception review is required if the Rx plan listed on the member's ID card is X1, X3, X4, M1, M2, M4, or B2 and the drug you've selected in the Rx Search tool displays the nondrug list symbol. For these drugs, submit a review using the Pharmacy Drug List Exception Request fax form. If we approve the exception, your cost will be charged, based on whether the drug is generic, brand, or specialty.  Learn more about drug benefit levels.

    Standard versus urgent review requests

    • Standard: We review most standard requests within 72 business hours. If we need additional information, the review could take longer.
    • Urgent: We typically handle these within 24 hours, whether or not adequate clinical information is available to make a decision. If there's not sufficient clinical information to approve the request, it may be denied.

    After we review the medication, we fax a decision to the requesting provider and send the customer a confirmation letter about the prescription coverage decision.

    • If we approve the request, the medication is covered by the customer's prescription benefits and can be filled at the pharmacy.
    • If we deny the request, the medication isn't covered by the customer's prescription benefits. The customer should then talk to his or her provider about choosing a different drug that's covered.

    Quantity limit or step therapy reviews

    Medications for certain conditions—such as migraines, diabetes, or high blood pressure—may need to meet certain requirements before a prescription is covered. See the Preapproval drugs section to check if the drug requires a preapproval, quantity limit, or step therapy review.

    Preapproval drugs

    Type the name of the drug to view preapproval criteria, the drug's corresponding medical policy, and a link to an online fax form. As another option, you can use the Pharmacy Preapproval Request fax form to submit all types of pharmacy authorization requests.

    Note: The Rx search tool shows drugs that require pharmacy preapproval common to all plans. To find out if your medicine requires pharmacy preapproval, sign in and access Express Scripts via your Pharmacy Services page.