The formulary is a list of your covered prescription drugs. It includes generic, brand name, and specialty drugs as well as Preferred drugs that, when selected, will lower your out-of-pocket costs.
Five-tiered Drug Formulary
Tiers are the different cost levels you pay for a drug. You will generally pay the lowest cost share for any Tier 1 generic drug or Tier 4 Preferred specialty drug. If your drug is in Tiers 2, 3 or 5, look to see if there is a generic or Preferred drug option available, and discuss these options with your doctor.
Basic and Standard Options
||Generic Drugs. Typically the most affordable, and are equal to their brand name counterparts in quality, performance characteristics and intended use.
||Preferred Brand Name Drugs. Proven to be safe, effective, and favorably priced compared to Non-preferred brands.
||Non-preferred Brand Name Drugs. These drugs have either a generic or Preferred brand available therefore your cost share will be higher.
||Preferred Specialty Drugs. Proven to be safe, effective, and favorably priced compared to Non-preferred specialty drugs.
||Non-preferred Specialty Drugs. These drugs typically have a Preferred brand available, therefore your cost share will be higher.
Managed Not Covered
Certain drugs are no longer covered under Basic Option. These drugs, known as “Managed Not Covered” drugs, have available covered options in the same therapeutic class. Click here for a full listing of “Managed Not Covered” drugs and available covered options. Basic Option members taking a “Managed Not Covered” drug should expect to pay the full cost of the prescription.
A few drugs are no longer covered on the Standard Option formulary. These excluded drugs have other drugs available that treat the same condition - either generic drugs, brand name drugs or both. These options are effective and safe, and they may help you save money on your prescriptions. Click here for a full listing of excluded drugs and available covered options. Standard Option members taking an excluded drug should expect to pay the full cost of the prescription.
Certain drugs on the formulary have quantity limits, which means your pharmacy benefit will only cover up to a specified, limited amount of the drug each time you fill a prescription or a limited amount per year. Quantity limits are often applied to ensure drugs are safely and appropriately used. Your prescribing doctor can request quantities greater than the allowed amount by submitting for Prior Approval through:
- Filling out the request form here
- Calling toll-free 1-877-727-3784
Some prescription drugs and supplies need approval in advance, or “prior approval” before we provide coverage for them. We need to find out if:
- The drug is related to a service or condition that is covered under the Service Benefit Plan
- The drug is prescribed in a way that matches generally accepted medical practices
Facts to know about prior approval:
- In providing prior approval, we may limit the amount of drugs you receive. We approve drug quantities (for example, number of pills) based on accepted standards of medical, dental, or psychiatric practice in the United States.
- You’ll need to renew your prior approval periodically.
- Drugs and supplies on the Prior Approval list may change throughout the year.
- Mail Service and Specialty Programs will not fill prescriptions that need prior approval until we approve your prior approval request.
- Preferred retail pharmacies will fill your prescriptions, but you will pay the full cost of the drug until we approve your prior request. Once you receive prior approval, you will then need to file a claim for reimbursement with the Retail Pharmacy Program.
For a list of drugs that need prior approval or to get a prior approval request form:
- Click here
- Call Customer Care any time toll-free at 1-800-624-5060