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Formulary Terms: What Do They Mean?

PRIOR AUTHORIZATION (PA) means a drug that requires prior approval before the Plan will cover it, and when the patient meets the established criteria. The doctor must submit a Prior Authorization Request Form. The doctor can submit the request by fax, phone, or regular mail.

STEP EDIT (ST) means a drug that requires a prescription history of specific drugs in the pharmacy claims or data system, and these specific drugs must be taken during a given time frame. After the specific drugs have been taken within the given time frame, online coverage of the newly-prescribed drug occurs at the pharmacy. Step Edits make it easier to access drugs that would normally require a Prior Authorization.

MEDICAL EXCEPTION means a drug that is not on the Plan's formulary. Non-formulary drugs require an exception to the formulary due to allergy, adverse reactions, or no response to all formulary drugs.

QUANTITY LIMIT (QL) means a coverage limit on the medication quantity covered for a defined days' supply (usually 30 or 90 days) based on safety, efficacy and/or dose optimization issues.

AGE LIMITATION (AG) means a coverage limit based on minimum or maximum age of the member imposed as a result of safety, efficacy or dosage form considerations.

SPECIALTY (SP) means high cost medications that are usually dispensed by a specialty pharmacy. Specialty pharmaceuticals are self-administered, meaning they are administered by the patient or to the patient by a family member or caregiver. Most specialty medications require prior authorization and are mandated to be obtained through the specialty pharmacy vendor.

MEDICAL DRUGS (MED) are defined as medications administered in the office or facility that require a healthcare professional to administer. These medications may be required to be dispensed by the specialty pharmacy vendor. Some Medical Drugs may require prior authorization before they can be obtained. Office administered applies to all outpatient settings including, but are not limited to, physician's offices, emergency rooms, urgent care facilities and outpatient surgery facilities.