Other Drug References

 

Changes to the drug list (formulary)
 

We update our covered drug list monthly. We may make changes based on findings from:

  • The Food and Drug Administration (FDA)
  • The Centers for Medicare & Medicaid Services (CMS)
  • Clinical standards of care

We don’t often discontinue or reduce drug coverage during the plan year. If we remove drugs from our list or add prior authorization, quantity limits or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify you. This must be at least 60 days before the change is effective. Or it may be when you request a refill of the drug. Then you’ll get a 60-day supply of the drug.

If the FDA views a drug on our formulary as unsafe or the drug maker removes the drug from the market, we’ll remove the drug from our formulary. We’ll send you a notice if you’re taking the drug.

 

Prior authorization, quantity limits and step therapy

 

Some covered drugs may have additional requirements or limits. These include:

 
Prior authorization
 

You or your doctor may need approval for certain drugs before you fill your prescriptions. If you don’t get approval, we may not cover the drug.


Quantity limits
 

For certain drugs, we limit the amount of the drug. We may limit coverage to 30 tablets for a 30-day supply. We may also limit fills to a one-month or three-month supply.

 
Step therapy


In some cases, we require you to first try certain drugs to treat your condition before we cover another drug for that condition. For example, if drug A and drug B both treat your condition, we may not cover drug B unless you try drug A first. If drug A doesn't work for you, we'll then cover drug B.

 
Look in the formulary for more requirements or limits.


If you’re a member, you can request an exception if your drug has a prior authorization, quantity limit, or step therapy requirement, or if the drug isn't covered on our formulary.



>Request Coverage Determination/Prior Authorization


 

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