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Prior Authorization is a process to ensure that certain drugs are prescribed appropriately, for specific conditions. It is not required for all drugs. Rather, it affects only a relatively small number of medications, which must receive Prior Authorization to be covered. So it's important that you and your doctor understand what categories of drugs are subject to prior authorization.

Message from Robert S. Galvin, MD, Director of GE Medical and Healthcare Programs Fairfield, Connecticut

One of the benefits GE employees, retirees, and family members value most is their comprehensive package of medical, dental, vision, disability and prescription drug coverage. That's because, for a modest contribution through weekly payroll deductions, an average GE family receives millions of dollars worth of health and disability coverage - and the peace of mind that goes with it. To keep these payroll deductions as low as possible, there are limits to what GE health benefits cover, and rules on some of the covered benefits.

The prior authorization program is part of your GE Prescription Drug coverage. It has been put in place to review a limited number of prescription drugs, to make sure they have been prescribed according to expert medical guidelines, and to make sure that they don't interact with other medicines you might be taking. For example, the new drug Celebrex is an innovative treatment for the pain and inflammation of arthritis. However, according to experts from the Food and Drug Administration (FDA), this drug is no more effective than prescription-strength Motrin in treating arthritis pain and inflammation. Yet it is three times more expensive. With the prior authorization program, we can ensure that prescription drugs are dispensed to those who need them, based on scientific and expert medical guidelines.

We are committed to applying this program fairly and with a focus on good customer service. I hope this web page will help you better understand how the prior authorization program works, give you some steps to take if you encounter any problems, and help guide you to the right source if you have any questions that are not answered.

• Why is the Prior Authorization rule in place?

  It's essential for both medical and financial reasons. Medically, it acts as a safeguard against drugs that can be:

  • Harmful (like Viagra, which can lead to heart attack when combined with nitrate drugs);
  • Ineffective for the prescribed condition (as in the use of growth hormones for a patient in whom no additional bone growth is expected);
  • Misused (like Retin-A, which is prescribed for serious acne, but is also used for cosmetic reasons).

  It also guarantees that health care dollars are used for drugs that are medically necessary, so that the right drug gets to the right person at the right cost for the right duration. Decisions about prior authorization are made with guidelines developed by physicians, either at the FDA or in independent expert panels.

• What kinds of drugs require Prior Authorization?

  Typically, they are drugs that are prone to misuse, or sometimes prescribed for uses not recommended by expert guidelines. Others, based on the manufacturers' recommendations, have been restricted to certain doses and quantities. Others may be covered only if less expensive therapies have proven ineffective - like using Celebrex instead of prescription-strength Motrin.

• What are the most common drugs requiring Prior Authorization?

  The most common ones include Celebrex, Vioxx, Viagra, appetite suppressants such as Xenical, smoking deterrents, fertility agents, and Retin-A. Drugs are listed based on the manufacturers' recommended uses, FDA regulations, and opinions of pharmaceutical and medical experts as compiled by Medco Health.

• Does this mean a drug requiring prior authorization is not covered by the plan?

  No, it means the drug is covered only when a patient is diagnosed with a very specific condition. For example, to receive coverage for Vioxx, a patient would have to be diagnosed with osteoarthritis or rheumatoid arthritis, and be at risk for stomach ulcers.

• How can I find out which drugs require Prior Authorization?

  • Go to the site of Medco Health (www.medcohealth.com), your GE Prescription Drug Administrator.
  • If you have not already registered, the process is simple.
  • After you log in, in the left-hand navigation column, under "Prescriptions and Benefits," click on "Benefit Highlights."
  • On the next page, in the wide middle column, click on the bullet called "Details on prescriptions requiring prior authorization." The list of drugs which require authorization will appear.

• What should my doctor do before writing a prescription for a drug requiring prior authorization?

  If you think that the drug the doctor wants to prescribe may be subject to prior authorization, ask the doctor to contact Medco Health at 1-800-355-4379 to determine if the drug will be covered.

  If it's determined that the drug is prescribed for use outside of the plan's conditions for coverage, a letter will be sent to you and your doctor indicating that coverage cannot be provided. If there are special circumstances that call for further consideration, your doctor may file an appeal in writing. Instructions for the appeal will be included in the letter to your physician.

• What steps can I take to ensure that I get the drugs I need right away, with full coverage?

  To help the process run smoothly, you simply need to understand the rules, and make sure your doctor understands them too. Specifically, make sure your doctor knows that:

  • Certain drugs require prior authorization.
  • If he or she prescribes one of these drugs, a coverage review is required. For this, your doctor simply needs to call Medco Health at 1-800-355-4379.

• What if my doctor doesn't contact Medco Health before I try to fill a prescription that requires Prior Authorization?

  • The pharmacist will be alerted that your prescription requires prior authorization when he or she processes it. In most cases, the pharmacist will call Medco Health to get the review process started. Medco Health will ask your physician to provide the required information.
  • This process typically takes two business days to complete. Once the review process is completed, Medco Health will notify your pharmacists of the review decision. You and your physician will also be notified in writing. In some cases your pharmacist will offer you a complimentary five-day supply while the review process is being conducted.
  • You always have the option of paying the full cost of the prescription and submit for reimbursement, as long as the prescription meets the coverage requirements.
  • Some pharmacists may not recognize the Medco Health name and may be more familiar with the name Paid Prescriptions LLC which is a subsidiary of Medco Health.

• Other Notes:

  • The use of generic drugs is encouraged, whenever applicable.
  • Help your doctor help you! Print this out and bring it to your next appointment and tell your doctor to clip it to your file.

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