Drugs Requiring Prior Approval, Step Therapy and/or Quantity Limits
Some prescription drugs may require prior approval, step therapy and/or be subject to quantity limits. It is very important to make sure that prior approval is received before filling your prescription.
The list of prescription drugs that require prior approval, step therapy and/or are subject to quantity limits are effective Jan. 1, 2013 and may change may change Jan. 1, 2014, depending on any CMS modifications.
Click here to view provider instructions for initiating a coverage review.
If you disagree with a decision made during the prior authorization process, you have the right to request that the State Health Plan or its representative review the decision through the appeal or grievance process. This process is voluntary and may be requested by the member or an authorized representative acting on the member's behalf. Please refer to your Evidence of Coverage document that you received in your welcome kit for more information or contact Express Scripts at the numbers listed below.
For Grievances:
Express Scripts Medicare
Express Scripts Holding Company
Attn: Grievance Resolution Team
P.O. Box 630035
Irving, TX 75063-0035
877-680-4882
For Appeals:
Express Scripts Medicare
Attn: Medicare Reviews
P.O. Box 630367
Irving, TX 75063-0118
800-935-6103
