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Medication Guide

List of Drugs Formulary
List of Drugs Change Notice
Prior Authorization Criteria
Step Therapy Criteria
Quantity Limits
Drug Coverage Determination (exceptions)
Generic Drugs
Mail Order Service

List of Drugs (Formulary)

Our list of drugs (formulary) shows the Part D drugs that we cover. In general, we cover your drugs if they are medically necessary. Drugs on our list of drugs are covered when you use our network pharmacies or mail order service for maintenance drugs. Maintenance drugs are drugs you take for a chronic or long-term condition. Some drugs we cover have limits or other rules.

The Pharmacy and Therapeutics Committee, our team of independent healthcare experts, reviews and approves our list of drugs. We don’t include all drugs. Some drugs may not be covered or are excluded. Other drugs are not on the list because of clinical and cost reasons.

How Do I Search for a Drug in the List of Drugs (Formulary)?

You can search for a drug by using either our Drug Search Tool or by opening the List of Drugs (Formulary) document. Each option gives you a complete list of covered drugs and any restrictions or limits. The search tool also shows you covered drug alternatives.

The PDF document lists drugs by medical condition and alphabetically within the index. To search for your drug in the PDF, hold down the “Control” (Ctrl) and “F” keys. When the search box appears, type the name of your drug. Press the “Enter” key. You also have the option to print the drug list as a PDF document. The drug list is updated monthly.

You can find the List of Drugs (formulary) Search Tool in the sidebar navigation.

You can find the List of Drugs (formulary) as a PDF document on the Drug List (Formulary) and Other Documents page in the sidebar navigation (within the Pharmacy section).

List of Drugs Change Notice

Drugs may be added or removed from our list of drugs during the year. Generally, we will tell you before we make one of the following changes to the list of drugs:

  • Remove a drug from the list.
  • Change drug requirements.
  • Move a drug to a higher cost sharing tier.

If the Food and Drug Administration (FDA) or the drug’s maker says a drug is not safe, it will be removed from our list of drugs right away. In addition, if a new generic drug comes to market, we may remove the brand name drug.

You can find the List of Drugs - Change Notice as a PDF document on the Drug List (Formulary) and Other Documents page in the sidebar navigation (within the Pharmacy section).

Prior Authorization, Step Therapy and Quantity Limits

  • Prior Authorization: We require you to get approval from us before we agree to cover certain drugs. We call this prior authorization. If you don’t get approval, you may be asked to pay for the drug. Drugs that require a prior authorization are noted with a “PA or PA-NS” on the List of Drugs (formulary).
  • Step Therapy: In some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. This requirement to try a different drug first is called step therapy. Drugs that require step therapy are noted with an “ST” on the List of Drugs (formulary).
  • Quantity Limits: For certain drugs, we limit the amount of the drug that we will cover. For example, one tablet per day. This may be in addition to a standard one-month or three-month supply. Drugs that require quantity limits are noted with “QL” on the List of Drugs (formulary).

You can find the Prior Authorization Criteria and the Step Therapy Criteria forms as PDF documents on the Drug List (Formulary) and Other Documents page in the sidebar navigation (within the Pharmacy section).

Drug Coverage Determinations

You can ask us to make an exception to our coverage rules for your drug(s). To learn about the types of exceptions, refer to your Evidence of Coverage. When asking for an exception, include a statement from your doctor that supports your request, plus a completed Coverage Determination form.

Generally, we must decide within 72 hours of getting your doctor’s supporting statement. You or your doctor can request a fast (expedited) exception if your health may be harmed by waiting. If we approve your expedited request, we must give you a decision within 24 hours after we get your doctor’s supporting statement.

You can find the Coverage Determination forms at the bottom of the Pharmacy page found in the sidebar navigation.

Generic Drugs

We cover both brand name drugs and generic drugs. Generic drugs have the same active ingredient formula as a brand name drug. Generic drugs are FDA-approved, and are as safe and effective as brand name drugs. They have the same active ingredients, indications, dosages, safety, and strengths as the brand name drugs and generally cost less. Ask your doctor if any of your drugs are available as a generic, and if a generic version will work for you.

Mail Order Service

You can fill your prescription at any network pharmacy. You also can fill your prescription through our preferred mail order service. This can save you time, money, and trips to the Pharmacy.

Find more information about receiving your prescriptions through mail service delivery on one of the following pages:

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Y0020_WCM_100876E Last Updated On: 10/1/2022