What is a Formulary?

A formulary is a list of drugs selected by the Prescription Drug Plan(PDP) in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. The Prescription Drug Plan(PDP) will generally cover the drugs listed on our formulary as long as the drug is medically necessary, the prescription is filled at a network pharmacy, and other plan rules are followed.

Both brand-name drugs and generic drugs are included on our formulary. A generic drug has the same active-ingredient formula as the brand-name drug. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and as effective as brand-name drugs.

What Are Cost-sharing Drug Tiers?

Drugs on our formulary are organized into different cost-sharing drug tiers, or groups of different drug types. The amount you pay for each prescription depends on which drug tier your medication is in.

Can The Formulary Change?

The Prescription Drug Plan(PDP) provider may add or remove drugs from our formulary during the year.  Changes in the formulary may affect which drugs are covered and how much you will pay when filling your prescription.  We will send written notice of changes to our formulary to all the Prescription Drug Plan(PDP) members who are using a particular drug.  Medicare requires a notice to be sent at least 60 days before the change will take effect.  A Formulary Change Notice will also be posted on this website of Prescription Drug Plan provider to alert you of changes.

However, if a drug is removed from our formulary because the drug has been recalled from the market, a notice is not required.  Instead, the Prescription Drug Plan(PDP) will remove the drug from our formulary immediately and notify members about the change as soon as possible.

How Can I Request An Exception To The Formulary?

You can ask the Prescription Drug Plan to make an exception to our coverage rules. Generally, the Prescription Drug Plan(PDP) will only approve your request for an exception if the alternative drugs included on the plan's formulary or the low-tiered drug would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

Your prescriber must contact the Prescription Drug Plan(PDP)  clinical prior authorization department to request an exception.

What is Utilization Management?

For certain prescription drugs, the Prescription Drug Plan(PDP) has additional requirements for coverage or limits on our coverage.  These requirements and limits ensure that our members use these drugs in the most effective way and also help the Prescription Drug Plan(PDP)  control drug plan costs.  Each Prescription Drug Plan(PDP) provider has a team of doctors and pharmacists developed these requirements and limits for the Prescription Drug Plan(PDP).  Examples of utilization management tools are described below:

• Prior Authorization: The Prescription Drug Plan(PDP) requires you to get prior authorization for certain drugs.  This means that you will need to get approval from The Prescription Drug Plan(PDP)before you fill your prescription.  If you don't get approval, The Prescription Drug Plan(PDP)may not cover the drug. 
• Quantity Limits: For certain drugs, The Prescription Drug Plan(PDP) limits the amount of the drug that we will cover per prescription or for a defined period of time. 
• Step Therapy: In some cases, The Prescription Drug Plan(PDP)requires you to first try one drug to treat your medical condition before we will cover another drug for that condition.  For example, if Drug A and Drug B both treat your medical condition, The Prescription Drug Plan(PDP)may require your doctor to prescribe Drug A first.  If Drug A does not work for you, The Prescription Drug Plan(PDP)will then cover Drug B.

You can find out if your drug is subject to these additional requirements by looking in the The Prescription Drug Plan(PDP) formulary.  If your drug does have these additional restrictions or limits, you can ask The Prescription Drug Plan(PDP )to make an exception to our coverage rules.  See the section above, "How Can I Request An Exception To The Formulary?