Prescription Drug Plan Rules
There are some special rules to know about your formulary.
Prior Authorization (PA)
Prior Authorization is required on some medications before your drug will be covered. The program applies to certain high-cost drugs that have the potential for misuse. If you are taking a medication that requires Prior Authorization, your physician must submit a Prior Authorization Request Form to Prime for approval. If the request is not approved, you may file an appeal or you can purchase the medication at your own expense.
The Step Therapy Program encourages safe and cost-effective medication use. Step Therapy requires the previous use of one or more drugs before coverage of a different drug is provided. If your plan reflects that Step Therapy is used for a specific drug, your physician must submit a prior authorization request form to the plan for approval. If the request is not approved, please remember that you always have the option to purchase the medication at your own expense.