Pharmacy benefit design

Formulary

Physicians are encouraged to use the formulary to optimize the drug benefit for our members and help minimize out-of-pocket expenses. 

For many HMO and POS members, prescription drugs that are not in the formulary are excluded from coverage unless prior authorization is obtained. Non-formulary drugs are available for PPO and HMO members with outpatient, three-tier drug benefits that cover formulary generic, formulary brand-name, and non-formulary drugs. However, the copayment required is significantly higher than the copayment for formulary drugs.

Medication supply and mail service

Members can receive up to a 90-day supply of maintenance medications through mail service pharmacies. Additionally, employer group plan members can also get up to 90-day supply at retail pharmacies. Medications are considered maintenance when the dosage has been stabilized and the patient is taking the medication on a regularly scheduled basis.

Injectables

Home self-administered injectables are covered under the outpatient Prescription Drug Program for most of our health plans. A home self-administered injectable is a medication that is injected subcutaneously by the member or family member on a regular basis, usually daily or weekly. These injectables usually require prior authorization review. 

Exclusions

(Including but not limited to*:)

1. Over-the-counter (OTC) medications, except insulins; or prescription drugs which have an OTC equivalent.
2. Medications indicated for cosmetic use.
3. Smoking cessation drugs for some plans.
4. Nutritional products.
5. Medications for investigational or experimental use. Benefit exclusions vary based on plan design.
6. Lost or stolen medications.

* Benefit exclusions vary based on plan design. (refer to EOC for full description)

Revised: 1/3/2023