STERLING RETIREE PRESCRIPTION DRUG PLAN

Drugs Requiring Prior Authorization

Drugs Requiring Prior Authorization
The Sterling Retiree Prescription Drug Plan Formulary clearly indicates which prescription drugs require Prior Authorization (PA) before the prescription can be filled. Quantity limits on certain drugs will also be clearly identified on the Formulary. To obtain PA on a drug, your prescribing physician must submit a PA Form to Sterling Retiree Prescription Drug Plan, your doctor can call our Customer Care Center and request that a form be faxed, e-mailed or mailed to him/her. A decision will be made within two (2) business days and it will be approved, pended or denied.

Pended
Additional clinical information is needed and will be reviewed within Two (2) business days after receipt.

Denied
The prescribing physician will be notified by phone and by written letter with the Appeals Process information. The plan will also notify you (the insured) in writing within 72 hours explaining the reason for the denial and will provide information on your rights to appeal any decision about your Medicare Part D Plan benefits.

Approved
If your request is approved by the Plan, the pharmacy you are using will be notified immediately and your prescription will be filled. An override and expiration date of the approval will be entered into the Plan’s adjudication system so you will be able to fill that particular prescription without delay until the approval’s expiration date.

Reasons Why a Prescription May be Rejected by The Pharmacy

• The drug is not on the Part D plan’s Formulary
• A physician did not receive prior approval from the Part D plan for the prescribed medication
• The specific drug dosage, method of administration (liquid verses pill) or type (generic versus brand name) is not on The Plan’s Formulary
• A previously covered drug is no longer on The Formulary
• The pharmacy filling the prescription is not within the Part D plan’s network
• The prescribed medication is not a Part D-covered drug.

You may request a copy of the IdealScripts Policies and Procedures at any time by contacting the Plans’ Customer Care center at 800-313-7667, Monday through Friday from 8:00 AM to 8:00 PM (Eastern).