Terms and Definitions
- Prior Authorization
Some medications won’t be covered unless you receive pre-approval. You may need approval for coverage of the drug or for coverage of additional quantities of a drug. Medications may fall under one or more programs. You can contact Express Scripts to determine if the medication you’re prescribed requires pre-approval.
- Step Therapy
This requires you to first try one or more specified drugs to treat a particular condition before the plan will cover another (usually more expensive) drug that your doctor may have prescribed. Step therapy is intended to reduce costs to you and your plan by encouraging use of medications that are less expensive but can still treat your condition effectively.
- Drug Quantity Management
Aligns the dispensed quantity of prescription medication with dosage guidelines approved by the Food and Drug Administration (FDA) or clinical evidence.
The National Preferred Formulary, Express Scripts’ standard formulary, preserves individual choice and access to clinically effective generic and brand-name drugs. The formulary includes nearly 100% of generics and more than 4,000 unique products.
- Coverage Review
For prescriptions that need pre-approval, you, your doctor, or your pharmacist may initiate the review by calling Express Scripts at 1-800-753-2851.
Smart90 Exclusive requires members to fill their maintenance medications at a Smart90 retailer, Walgreens, or through our home delivery pharmacy, and at a 90-day supply.
The plan offers convenient access to vaccines from local retail pharmacies.