Formularies and drug search
Your prescription drug benefit is based on a list of covered drugs called a formulary. A group of independent doctors and pharmacists chooses the drugs for our formularies based on their effectiveness, safety and value. If you want to save the most on your drug costs, ask your doctor if a generic or preferred brand-name drug is right for you.
Different formularies may cover different drugs, place drugs at different copayment tiers or have different management programs. Speak with your human resources department or refer to your benefit document if you’re not sure which of the following applies to you.
Drug pricing
Use theDrug Price Estimating Tool to find out how much you can expect to pay out-of-pocket for a specific drug, plus lower cost options, if available.
Drug tiers
Each drug in the formulary is assigned a tier under your benefit plan. Each tier is associated with a copayment or coinsurance amount. This is the amount you pay when you get a prescription. Refer to your benefit document to find the amounts that apply to you.
Common tier groupings include:
- Generic — For the lowest out-of-pocket expense, you should always consider generic drugs if you and your doctor decide they are right for you.
- Preferred Brand — Consider preferred brand-name drugs if no generic drug is available to treat your condition.
- Nonpreferred Brand — These are usually the highest-cost products. When a generic becomes available, most of the time the brand-name version will move to nonpreferred status.
- Specialty — Most plans have one or more tiers designated for specialty drugs.
Nonformulary and excluded drugs
From time to time, our pharmacy committee may decide to no longer cover some drugs. The committee does this when other safe, effective, less costly alternatives are available. Those drugs are then moved to nonformulary status. Additionally, some plans may exclude coverage for certain categories of drugs, such as those for weight loss, fertility or sexual dysfunction. You and your doctor always have the freedom to choose the medication that works best for you. Find more information here.
Drug management programs
Not all members have all of these programs. Also, different formularies may include different drugs within these programs. Please check your Schedule of Benefits to find out which ones apply to you.
- Prior Authorization — Most of our members need prior authorization for certain drugs.
- Quantity Management — This program limits the amount of certain drugs your plan will cover.
- Step Therapy — This program requires members to try one or more Step 1 drugs before their plans will cover Step 2 drugs.Speak with your human resources department or refer to your benefit document if you’re not sure which of the following applies to you.
Specialty drugs
Specialty drugs are prescription medications that are used to treat complex or chronic medical conditions like cancer, rheumatoid arthritis, multiple sclerosis and hepatitis, just to name a few. Depending on your plan, you may pay a different copayment or coinsurance for specialty drugs under the pharmacy benefit.
Some members are subject to separate management programs for specialty drugs that are covered under their medical benefit. For those members, some medical (injectable or infusible) specialty drugs require prior authorization. In addition, some infused specialty drugs must be administered at a specific site of care, such as at home or at an infusion suite. Certain self-administered specialty drugs are only covered under the pharmacy benefit.
- Medical Drug List (includes information on prior authorization and site of care)
- Self-Administered Drug List
Maintenance drugs
Maintenance drugs are prescription drugs you take on a long-term basis. They may be used to treat a chronic condition or may be products taken routinely, such as birth control pills. Prescriptions for these products often can be filled for 90 days at a time. Some health plans require 90-day fills for maintenance drugs.Check your member guide for details.
Mail service
Somehealth plans include a mail service benefit. Home delivery by mail is an easy and convenient way to save time and trips to the pharmacy. If you are eligible for this service, please call the home delivery pharmacy at 855-811-2218. A representative will explain the steps you will need to take to set up mail service. Check your benefit documents to see if your health plan offers mail service.
Preventive drugs
These are drugs that may help prevent serious illnesses and complications. Taking preventive drugs, as directed by your doctor, may help you live a healthier life today and avoid serious illness in the future. Under health care reform, the Affordable Care Act requires most health plans to cover certain drugs at $0 cost to members. Additionally, IRS guidelines for high-deductible health plans provide that preventive care, including prescription medications used for preventive purposes, can be excluded from the deductible. Talk to your benefits coordinator to learn if your plan offers this benefit.
Generic drugs
Generic drugs become available when patents expire on brand-name drugs. They contain the same active ingredients as brand-name drugs but are not manufactured under a brand name or trademark. The color and shape of the generic drug may be different from its brand-name counterpart, but the active ingredients are the same for both. Generic drugs must meet the same U.S. Food and Drug Administration quality standards as the brand-name drugs.
Some members have a Dispense as Written generic program as part of their prescription drug benefit. This means if a member has a prescription for a particular brand-name drug that is also available in generic form, he or she will pay more for that brand-name drug if he or she opts to fill it instead of the generic version. If your doctor feels that the generic version is not appropriate for you, he or she can request an exception detailing why the member must have the brand-name drug over the generic version.
No-cost blood glucose meter
Monitoring your blood sugar is an important part of managing diabetes. That’s why we encourage our members to use OneTouch® products. OneTouch products are preferred on ourformulary which means switching to OneTouch can save you money.
Talk to your doctor about whether OneTouch is a good option for you. If your doctor agrees to the switch, you can get a new OneTouch meter at no cost to you. Several options are available.
To get your free OneTouch meter, just print this voucher and take it, along with your member ID card, to a network pharmacy. Your doctor will need to write you a prescription for your new OneTouch test strips. All other test strips are nonpreferred and require prior authorization.
Medication adherence
The treatment of chronic illnesses often requires the long-term use of prescription drugs. While these long-term, or maintenance, medications are effective in combating disease, many patients don’t get their full benefits because they don’t take their medications as prescribed. Proper use of prescription drugs is called medication adherence. If your plan includes the medication adherence program, you may get letters or phone calls if we note that you haven’t been keeping up with taking your medication. Medical conditions that are monitored within the program include diabetes, hypertension, high cholesterol and other chronic conditions.
Opioid management
To help fight the ongoing national opioid crisis, we have put a program in place based on U.S. Centers for Disease Control and Prevention guidelines. It consists of daily quantity limits specific to each covered opioid drug. It also includes prior authorization requirements for certain prescribing situations. It limits the amount of opioid medication we will cover for first-time prescriptions.
