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As you write prescriptions for your patients, it’s important to be aware that some medications have special requirements that must be met before the prescription can be filled. Here’s what you should know.
Prior Authorization
Certain medications, such as Enbrel, Lamisil, Sporanox and Viagra, require prior authorization from Express Scripts before they can be filled at the TRICARE Mail Order Pharmacy (TMOP) or network retail pharmacies under the TRICARE Retail Pharmacy (TRRx) Program. Prior authorization is necessary to ensure that clinically appropriate treatment regimens are followed. Drugs that require prior authorization are usually medications that are not the first step in a treatment regimen. The Department of Defense (DoD) Pharmacy and Therapeutics Committee determines the criteria for prior authorizations and which drugs are subject to those criteria.
Except for antifungal medications, prior authorizations are good for a year, even if several new prescriptions for the medication are submitted during that year. Prior authorizations for the antifungal medications used for fungal infections of the fingernails or toenails (itraconazole, terbinafine and ciclopirox) must be approved for each new course of therapy.
Quantity Limits
Quantity limits are a common practice in commercial health plans to help ensure beneficiaries receive the proper dose and recommended duration of therapy to optimize outcomes while minimizing potential for adverse events, inappropriate therapy and waste. The DoD Pharmacy and Therapeutics Committee has established quantity limits on certain medications, which means the DoD will pay only for up to a specified quantity per 30-, 60- or 90-day supply. Exceptions to established quantity limits can be made if the prescribing physician is able to justify medical necessity.
Get the Details
Express Scripts Pharmacy Prior Authorization Forms and complete lists of medications that require prior authorization or are subject to quantity limits are available through the Express Scripts Web site at http://member.express-scripts.com/dodCustom/home.do (choose the link “Drugs that Require Prior Authorization” or “Drugs that Have Quantity Limits”). Or, you can call 1-866-DoD-TRRx.
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