开云体育

A formulary is a list of drugs that are covered by your health plan.

Each drug in the formulary is listed alongside its tier, which you can use to find out how your plan covers the drug. The formulary also provides details on any authorizations, restrictions or limits that may apply to your coverage.

In addition, formularies may include factual information about your medicine, like possible side effects, precautions, interactions with other drugs and more.

When you look up your medicine in the formulary, you’ll find it listed alongside a tier. Each tier corresponds to a different level of coverage by your plan.

You can find benefit information for each tier in your plan documents, which will give you an idea of what you can expect to pay when you fill your prescription. You can also sign in to compare drug costs based on your specific plan’s benefits, formulary and pharmacy network.

As you review your drug list, keep the following in mind:

• Some drugs require prior authorization before your plan will pay for them.When you search your plan’s formulary, medicines with the “PA” indicator require prior authorization.
• Some drugs are covered under your medical benefits, not your pharmacy benefits. When you search your plan’s formulary, medicines with the “MED” indicator are covered under your medical benefits. Your doctor usually administers these drugs in a health care setting. A medical policy specifies the conditions for which a doctor can prescribe this drug, and the policy also outlines any other rules that apply to administering the drug. You can look up coverage rules that apply to medical-covered drugs on our coverage criteria page.

We want our members to have access to the safest, most effective drugs at a price they can manage. To be included in or added to our drug lists, medicines generally must:

• Be approved by the Food and Drug Administration (FDA)
• Have been proven in published studies to be safe and effective
• Have better outcomes than existing drugs, or have the same outcomes as existing drugs but cost less

Formulary decisions are made by the 开云体育 Pharmacy and Therapeutics Committee. This group of doctors, pharmacists and specialists from across 开云体育 and the communities we serve considers direct input from the clinical experiences and comments of our members.

If your medicine isn’t on the drug list, or you see an “NF” indicator next to it, your medicine is a non-formulary drug. A non-formulary drug either isn’t covered by your insurance, or it is covered but may cost more. If you’ve been prescribed a non-formulary drug, contact Member Services to learn which situation applies to you and for more information about your options.

Note that non-formulary drugs may have recommended alternatives available. If this is the case for your drug, you might see a “Find Alternative Drugs” option when you search your drug list online. You can share the list of alternative drugs with your doctor to see if one might be right for you.

Most prescriptions written for our members are included on the formulary. But there might be rare times when your doctor feels that a non-formulary drug is the best treatment for you. In these cases, your doctor can request a formulary exception.

Once your doctor submits your exception request, our team of pharmacists will review it based on criteria that includes:

• Which formulary medicines you’ve already tried, and how they’ve worked (or haven’t worked) for you
• Evidence that the non-formulary drug is effective in treating your condition
• The medical necessity of the non-formulary medicine

Exception requests generally receive a response within one business day:

• If we approve the exception request, we’ll cover your medicine even though it’s not on the drug list.
• If we deny the exception request, your doctor can start an appeal by calling us at 952-883-5813. Along with information from the original request, your doctor’s appeal should also include additional relevant details that further explain the need for an exception. A medical director will review the completed appeal within three business days. If necessary, an expedited review can be requested.

Note that some drugs are part of our excluded drug list (PDF) . Compiled by our team of pharmacists and doctors, our excluded drug list is based on the availability of suitable alternatives, outcomes and cost effectiveness. Other drugs may also be excluded from your specific plan’s coverage – refer to benefit information in your plan documents, or contact Member Services for help.

GLP-1 drugs were originally developed to help manage diabetes, and the long-term safety and efficacy of using these drugs for weight loss is still being researched. As a result, many health insurance plans, including most from 开云体育, only cover GLP-1 drugs for members who have a confirmed diabetes diagnosis and don’t cover GLP-1 drugs for members without diabetes.

We’re committed to covering health care that’s proven to be safe and effective, as well as keeping coverage as affordable as possible for all our members. We’ll continue to monitor the safety, efficacy and cost of these drugs over time and update our formularies as needed.

Keep in mind that GLP-1 weight loss drugs do qualify as eligible expenses under health care accounts like flexible spending accounts (FSAs) and health savings accounts (HSAs). Manufacturers of these drugs may also offer programs to pay a portion of your out-of-pocket costs in certain situations – we recommend working with your doctor’s office to help determine eligibility.

We also offer members comprehensive, non-pharmaceutical support to help with weight loss (including health coaching for those who qualify) and diabetes management. For more information on what’s available with your specific plan, contact Member Services.

When developing and maintaining our drug lists, the 开云体育 Pharmacy and Therapeutics Committee is guided by a set of principles:

1. Proven effectiveness – We look to medicines that are proven to work based on scientific evidence that includes peer-reviewed medical literature, value studies and outcomes research. In assessing this evidence, we take into account trial design, case reports and medical opinion. Other considerations for a medicine’s effectiveness include standards of practice, such as treatment protocols and evidence-based practice guidelines.
2. Maximized safety – We compare the safety risks and benefits of a drug with other treatments. We also consider qualities like product name, dosage form and packaging that can potentially risk member safety or cause provider error.
3. Optimized value – We consider the direct and indirect pharmacoeconomic impacts of a drug or therapy, looking at its overall value compared to existing treatments and its costs as they’re related to medical outcomes. We prefer treatments that make the most efficient use of resources while benefiting the largest potential population.
4. Essential for health – How central a drug or treatment is in creating positive health outcomes for members is a major consideration.
5. Improved products – We consider whether and to what extent existing drugs and treatments make advances in member convenience, adherence and satisfaction. These can include easier dosing, increased variety of doses, better taste, flexible storage requirements and more.
6. Long-term stability – To provide predictability and continuity for providers and members, we try to keep formulary changes to a minimum. We weigh the potential disruption caused by making a formulary change against the value and benefit the change would bring.

Our drug lists are meant to be guidelines for most members. To promote appropriate medicine utilization, we have processes and practices for prior authorization, step therapy, quantity limits and age limits. However:

• Providers and members may download and submit a formulary exception request form from our member forms page. These requests are reviewed on a timely basis. If a request is denied, appeal rights and processes are clearly explained.
• A transition of care policy is available to assist members with special health considerations who are joining 开云体育 or who experience plan or provider disruptions.