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
A maximum of one month's supply of medication can be dispensed from participating retail pharmacies. Up to a 60-90 day supply may be available through mail service for maintenance medications. Medications are considered maintenance when the dosage has been stabilized and the patient is taking the medication on a regularly scheduled basis.
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.
(Including but not limited to*:)
- Over the Counter (OTC) medications, except insulins; or prescription drugs which have an OTC equivalent.
- Medications indicated for cosmetic use.
- Weight loss drugs, except for use in morbid obesity.
- Smoking cessation drugs for some plans.
- Nutritional products.
- Medications for investigational or experimental use.Benefit exclusions vary based on plan design.
- Lost or stolen medications.
* Benefit exclusions vary based on plan design. (refer to EOC for full description)