Lehigh’s prescription drug program is based on a three-tiered formulary that determines the amount of coverage you will receive for your drugs. Those tiers are Generic, Formulary Brand Name and Non-Formulary Brand Name medications. There are, however, eight classes of medications in which there are preferred and non-preferred drugs:
PPIs (proton pump inhibitors) —used to reduce stomach acid
SSRIs (selective serotonin re-uptake inhibitors) — used to treat depression, anxiety, and some personality disorders
Osteoporosis — used to strengthen fragile bones
ARBs (angiotension II receptor blockers) — used to reduce blood pressure
INS (intranasal steroids) — used to treat nasal allergies
Hypnotics (insomnia medications) — used to treat sleep disorders
Triptans — used to treat migraine
Glaucoma — used to treat increased pressure in the fluid inside the eye.
When you are prescribed a drug in one of these eight classes, Express Scripts will use its Preferred Drug Step Therapy Program (PDST) to determine coverage. In general, Express Scripts considers all ingredients in the medications in each class to be equivalent. Preferred drugs are then selected based on their cost.
What To Do If You Are Prescribed A Non-Preferred Drug
If your doctor prescribes a non-preferred drug, Express Scripts will inform the pharmacist, who will then let you know that the drug isn’t covered. At this point, your doctor can either change the prescription to a covered Generic or Preferred drug in the same class, or confirm to Express Scripts’s satisfaction that there is evidence of a medical reason for prescribing the specific medication. The doctor will need to fill out and return a fax form with the necessary clinical information.
Express Scripts understands that some patients are either allergic to, or receive no benefit from, an equivalent Preferred medication. That is why there is an exception policy. Even if you aren’t granted an exception at first, there is still another level of appeal possible. All decisions to cover the non-preferred drug, however, do require clinical evidence to justify the exception.