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Express Scripts - Prior Authorization ListExpress ScriptsPrescription Drug Prior Authorization Listfor Dominion EnergyAttached is a listing of prescription drugs that are subject to priorauthorization. This list is subject to change.Prior Authorization Hotline. The most efficient way to initiate a priorauthorization is to ask your physician to contact Express Scripts’ priorauthorization hotline at 1-800-753-2851.If the request is approved, your doctor will be notified. An approval code isprovided to the pharmacist for the claim to be processed. You will need to followup with your doctor to see if approval was received. If approval was received, thenext step is to contact the pharmacist so that the prescription can be processed.If the request is not approved, your doctor is notified during the call, and a followup letter is sent to you and your doctor.Prior Authorization Form. If your doctor wishes to complete a priorauthorization form instead of calling Express Scripts, the form can be obtained bycalling Express Scripts at 1-866-282-0547 or by visiting the Express Scriptswebsite at www.express-scripts.com. After the form has been completed, it canbe faxed to Express Scripts at 1-877-251-5896 for review. Express Scripts willnotify your doctor of the approval or denial within 48 hours of receipt of the priorauthorization form.Electronic Prior Authorization. Visit https://www.express-scripts.com/pa formore information. Physicians and their office staff can request a priorauthorization electronically, through their choice of the following tools: ExpressPAth secure online portal CoverMyMeds secure online portal Surescripts CompletePA secure online portal Within your existing ePrescribing software. Check with your vendor toensure you have the latest software version enabling Electronic PriorAuthorization (ePA).With ePA, Physicians will see several benefits: Clear direction on clinical requirements to get medicine to your patientsmore quickly Capability to proactively request new PAs and renew existing PAs beforethey expire Secure and efficient PA administration all in one place Only answer the necessary questions for the PA, unlike all questionsincluded in PA fax forms Ability to attach clinical documentation with guidance as to when it isrequired for the PA Most times, PA decisions take only minutes1
Express Scripts - Prior Authorization ListMedicationABSTRALACTEMRAACTHAR GELACTIQADAGENADCIRCAADDYIADEMPASADLYXINADVAIR DISKUSADVAIR HFAADVATEADYNOVATEAFINITORAFSTYLAAIMOVIGAIRDUO PROLIXALUNBRIGAMPYRAANDRODERMANDROGELARALAST EVECGOCOVRIGRANIXGRASTEKHAEGARDAHARVONIHELIXATE FSHEMLIBRAHEMOFIL N-ARETIN-A TEKRINVOQRITUXANRITUXAN FORSILIQSIMPONISIMPONI PRYCELSTELARA2
Express Scripts - Prior Authorization TA VA IVBOSULIFBOTOXBRAFTOVIBREO ELLIPTABYDUREONBYDUREON NE ATE SSUPARTZSUPARTZ FXSUPPRELIN LUCENTISLUMIGANLUMOXITILUPANETALUPRON DEPOTLUPRON AZAROTENETAZORACTECFIDERATEGSEDITEMODAR RETMAYZENTMEKINISTTESTOPELTESTOSTERONE CYPIONATETESTOSTERONE ENANTHATETHALOMIDTIBSOVOTIGLUTIK3
Express Scripts - Prior Authorization EVENITYEXJADEEXONDYS FILNPLATENUBEQANUCALANUPLAZIDNUTROPIN AQNUTROPIN AQ LUMIANTOMNITROPEONCASPARONFIONIVYDETOBITOBI PODHALERTRACLEERTRAVATAN ZTREANDATRELSTARTREMFYATRETIN XTRETINOIN TOPICAL ENDVICTOZAVIEKIRA EESIVYNDAMAXVYNDAQELWILATEXALATAN4
Express Scripts - Prior Authorization IRST-TESTOSTERONE MCFLEBOGAMMA OLDGAMIFANTGAMMAGARD LIQUIDGAMMAGARD LIQUIDGAMMAGARD ONEGELSYN-3GENOTROPINGENVISC X IVIGENPROCRITPROFILNINEPROLASTINPROLASTIN AIRXOSPATAXPOVIOXTANDIXYNTHAXYNTHA OZYDELIGZYKADIAZYTIGAPhysicians may call 1-800-753-2851 to initiate a prior authorization review or fax acompleted prior authorization form to 1-877-251-5896.5
Attached is a listing of prescription drugs that are subject to prior authorization. This list is subject to change. Prior Authorization Hotline. The most efficient way to initiate a prior authorization is to ask your physician to contact Express Scripts' prior authorization hotline at 1-800-753-2851.
