1. What is a formulary?

A formulary is a list of drugs selected by your plan 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. Your plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a participating network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

2. Can the formulary change?

Yes, your plan may add or remove drugs from the formulary during the year. To get updated information about the drugs covered by your plan, please access the online formulary or call us at the number located on the back of your ID card.

If we make changes to drugs listed on the formulary, we must notify members who take the drug.  For example, if a drug you take is to be removed from our formulary, we must notify you at least 60 days before we remove it or at the time you request a refill of the drug. At that time, you would receive a 60-day supply of the drug.  However, if the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.

3. How much will I pay for covered drugs?

The amount you pay depends on which tier your drug is under our plan. (You can find out which tier your drug is in by looking at the Comprehensive Formulary).

Please note:  If you qualify for financial help with your drug costs, your costs for your drugs may be different than those described below. Please refer to your Evidence of Coverage or call our member services unit to determine your costs.

When you first fill your prescriptions, the amount you pay depends on whether you go to a retail pharmacy or use a mail order pharmacy. Generally, when you go to a retail pharmacy you will pay for a 30-day (1 month) supply.  Select retail pharmacies will provide a 90-day (3 month) supply. For certain medications, if you fill your prescription through your plan's mail-order pharmacy, you can get a 90-day (3 month) supply for only 2 1/2 times (rather than 3 times) the cost for that medication. 

You will pay a copayment or coinsurance (percentage) for your drugs until your total drug costs (the amount you paid, plus the amount your plan has paid) reach $2,830. Once your total drug costs reach $2,830, there is a gap in your coverage. This means you have to pay the full amount for your prescription drugs until you have paid $4,550 out-of-pocket. After you have paid $4,550 out-of-pocket, the amount you pay depends on the tier for that particular drug. Generally you will pay the greater of: $2.50 for generic or a preferred brand drug that is a multi-source drug, $6.30 for all other drugs, or 5% coinsurance.

You can ask your plan to make an exception to your drug’s tier placement. Refer to the Appeals & Grievances section (Click here) for instructions on how to request an exception.

4. Are there any other restrictions on coverage?

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

• Prior Authorization: Your plan requires you to get prior authorization for certain drugs. (You may need prior authorization for drugs that are on the formulary or drugs that are not on the formulary and were approved for coverage through our exceptions process.) This means that you will need to get approval from your plan before you fill your prescriptions. If you don’t get approval, your plan may not cover the drug.
  
  Prior Authorization Drug List
• Quantity Limits: For certain drugs, your plan limits the amount of the drug that they will cover. For example, your plan provides 4 units per prescription for FOSAMAX per 30 days. This may be in addition to a standard 30-day or 90-day supply.
• Step Therapy: In some cases, you are required to first try certain drugs to treat your medical condition before your plan will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, your plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, you plan then will cover Drug B.

You can find out if your drug has any additional requirements or limits by looking at the online formulary.  You can ask your plan to make an exception to these restrictions or limits.

5. What if my drug is not on the formulary?

If your drug is not included in the formulary, you should first contact the plan's member services unit and ask if your drug is covered. If you learn that your plan does not cover your drug, you have two options:

• You can ask about similar drugs covered by your plan.
• You can ask your plan to make an exception and cover your drug. See information in “How do I request an exception to your plan's formulary”.

6. What are generic drugs?

Your plan covers both brand-name drugs and generic drugs. 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 approved by the Food and Drug Administration (FDA).

7. Do I have access to mail order drugs?

Yes. Certain drugs are available via mail order. Your plan determines which drugs will be on the mail order list. Generally, drugs on the mail order list are maintenance medications that are appropriate for long-term use for the majority of members. We cannot grant individual exceptions to the standard mail order list. Some of the drugs that are excluded include non-maintenance medications, all controlled substances, warfarin (Coumadin) and methotrexate tablets (Rheumatrex). Members may call the member services unit at the number listed on their ID card or under Contact Us to inquire about whether specific medications are covered through mail order.

8. How do I fill a prescription through my plan’s mail order pharmacy service?

To get order forms and information about filling your prescriptions by mail, please contact a participating mail order pharmacy member services number listed in the Online Pharmacy Locator . Please note that you must use a participating mail order network pharmacy. Prescription drugs that you get through any other mail order service are not covered.

When you order prescription drugs by mail, you must order at least a 60-day supply, and no more than a 90-day supply of the drug.

You are not required to use mail order prescription drug services to obtain an extended supply of maintenance medications. Instead, you have the option of using a preferred retail pharmacy in your plan's network to obtain a maintenance supply of medications. Some retail pharmacies may agree to accept the mail order reimbursement rate for an extended supply of medications, which may result in no out-of-pocket payment difference to you. Please look in your Evidence of Coverage or call the member services department at the number listed on the back of your ID card for more information.

Mail order drugs may take up to five (5) business days to process from receipt. Please allow ten (10) to fourteen (14) days from mailing your prescription for your medication order to arrive at your address. Refills ordered via the internet may arrive sooner.

If an order is delayed, please contact the applicable mail order pharmacy member services department at the phone number listed in the Online Pharmacy Locator .