Policies and processes
Drugs requiring prior authorization
Some medications require approval beyond the clinician’s prescription before they can be dispensed. This process ensures appropriate use of certain drugs which are approved for very specific conditions. When prescribing any of these drugs, the clinician will submit a prior authorization form to the Pharmacy, documenting the clinical need for the medication as well as other clinical criteria related to the use of the medication. This form will then be reviewed by a clinical team. This team will work with your clinician to review the request and develop the optimal therapy for you. If the request is approved, a member of this clinical team will notify you of the approval. If the request is not approved, both you and prescribing clinician will be notified. Denials can be appealed through the Yale Health Plan Appeal process.
Below is a list of drugs that are affected by this process. Prior authorization is required for these medications as well as for all brand name drugs for which there are generic equivalents. Please remember that this list is constantly being updated as new information and new drugs become available.
- Anzemet
- Arava
- Avonex
- Betaseron
- Bextra
- Botox
- Cialis
- Copaxone
- Copegus
- Emend
- Enbrel
- Forteo
- Genotropin
- Hepsera
- Humatrope
- Humira
- Neocate formulas
- Prescription proton pump inhibitors (PPIs) such as omeprazole, Aciphex, Nexium, Prevacid, Protonix
- Peg-Intron
- Pegasys
- Polygam and other intravenous immune globulins
- Rebetrol
- Regranex gel
- Remicade
- Temodar
- Tobramycin nebulas
- Xeloda
- Xolair
- Zelnorm tablets
- Zofran
- Zyvox tablets
The right quantity at the right time
The Pharmacy staff continually monitors prescription use and member medical histories for possible drug interactions, duplicate therapies (two or more drugs in the same class being used at the same time), and for both under-utilization of medications (most common when someone is on a maintenance medication over a long period of time) and over-utilization of medications. Medication over-utilization is monitored through guidelines established for each medication by the drug manufacturer, FDA or YUHS Pharmacy and Therapeutics Committee. Medication use monitoring is accomplished by matching the directions for use (for instance, one tablet daily) with the amount dispensed to you per month (for instance, 30 per month) or by establishing a maximum quantity of medication per month.
Some medications are dispensed only in limited quantities at one time, while others have limits on the quantity covered under your prescription drug benefit. In general, medications are grouped into the following categories: maintenance medications (taken on a regular schedule for chronic conditions such as high blood pressure, diabetes and asthma); acute and “as needed” medications (such as pain relievers or allergy medications), and medications that fall into separate quantity limit categories. This latter group may have a clinical limitation on the amount that can safely be used in a certain time period and include new migraine therapies, certain inhalers, nasal sprays, certain anti- nausea medications, and other medications that have a potential for misuse. For a sample list of medications in this group click on the link below. This list is not all inclusive and will be updated periodically to reflect changes in prescribing guidelines.
Supply guidelines for each category are as follows for both new and ongoing prescriptions:
| Acute medications | new Rx 15 days | refill Rx 30 days |
| Maintenance medications | new Rx 30 days | refill Rx 100 days |
If you need to request additional medication because you are going away for an extended period of time you will need to contact your clinician, who will fill out a prior authorization request and submit it to the Pharmacy. It will be reviewed and you will be notified about the outcome. Please make requests for any additional supplies at least 10 days prior to your needing your medication so that we can have sufficient time to process your request.
