How to Find Out if a Drug is Covered

When you are prescribed a new drug, it’s a good idea to look it up in the formulary to make sure it’s covered, find out what tier it’s on, and see if your drug has any special requirements. The formulary (drug list) lists all the drugs we cover alphabetically and by medical condition so they’re easy to find.

What if your drug isn't listed?

If your drug is not listed on the formulary, you may be able to get a temporary supply in certain circumstances. This gives you time to talk to your doctor and see if another prescription would meet your needs. Temporary supplies for new members are generally a 30-day supply, and available one time only during the first 90 days of your membership.

What is a tier?

Every drug in the formulary (drug list) has a tier number. You’ll find the tier number listed next to each drug. The tier number determines the general cost of the drug. In general, the lower the tier, the lower your cost for the drug. Plus, if the retail amount for a drug is lower than your copayment, you pay the lower amount.

Generic drugs on Tier 1 can help you save

A generic drug has the same active-ingredient formula as a brand name drug and can help save you money on prescription drug costs. Generic drugs are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs. If you take a brand name drug, ask your doctor if there is a generic version that is right for you.

Please note, prescription drug information may be different if you receive your benefits from a current or former employer.

Does your drug have a special requirement?

Some drugs have special requirements. The formulary (drug list) will tell you if a drug has special requirements, such as:

• Prior Authorization (PA) - Some drugs require you or your doctor to request special permission from us before you fill your prescription.
• Step Therapy (ST) - Some drugs require you to try a less expensive drug first. Medications with step therapy have at least one comparable medication that you must try first.
• Quantity Limit (QL) - For quality and safety reasons, certain drugs have a limit on the amount you can get at one time. For example, a medication may have a limit of 30 pills in 30 days.

If your drug has a special requirement, you or your doctor may need to take extra steps in order for your drug to be covered. Call Member Services or check your Evidence of Coverage (EOC) for details on what you can do to get coverage for the drug. You can also ask us to remove a special requirement by requesting an “exception”. Your EOC includes information on how to request an exception. We are not able to remove special requirements in all cases, but each exception request is reviewed to see if removing the restriction is possible.