Formulary Management
The drug list, also called a formulary, includes both brand and generic drugs. It will tell you whether any restrictions or limitations to coverage exist such as:
- Prior authorization
- Step therapy
- Quantity limits
Drugs that are subject to these rules are clearly labeled in the drug list and on our drug pricing tool.
We may periodically make certain changes within our formulary, such as:
- Adding or removing a drug from the drug list
- Moving a drug to higher or lower tier
- Adding or removing coverage restrictions
- Replacing a brand name drug with a generic
- Or if the U.S. Food and Drug Administration finds that a drug on the formulary is unsafe and the manufacturer removes it from the market, we will update our formulary accordingly.
If you happen to be taking any of the drugs that fall within these changes, we will notify you of these changes.
We may have monthly changes to our formulary. This means that certain drugs may no longer be covered. Please check the current formulary for list of covered drugs and talk to your doctor to see if an alternative covered drug is appropriate or to ask us for an exception.
Formulary
Prior Authorization Criteria
A prior authorization may be required for certain prescription drugs.
Step Therapy Criteria
You may be required to try a certain drug to treat your medical condition before another drug is covered for that condition.
- Important Message About What You Pay for Vaccines – Our plan covers most Part D vaccines at no cost to you, even if you haven’t paid your deductible. Call Pharmacy Member Services for more information.
- Important Message About What You Pay for Insulin – You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on, even if you haven’t paid your deductible
