Frequently Asked Questions

• Have dangerous side effects or can be harmful when used with other drugs.
• Are only used for certain health conditions.
• Patients often misuse or abuse
• Have a generic substitute (your doctor must complete the Brand Name Request Form and Express Scripts must approve the request before you can get the brand-name drug).
• Have age limits.
• Are for more than the normal limit.

A medical necessity approval allows you to pay the formulary copaymentA fixed dollar amount you may pay for a covered health care service or drug. for a non-formulary drug.  Express Scripts must approve the request.  

Your provider may prove medical necessity if a formulary drug:

• Creates risks or side effects.
• Is contraindicated.
• Is not effective.
• Is not an alternative.