Drug Formulary

The Drug Formulary is a comprehensive list of prescription medications covered under participating health plans. It is designed to support safe, effective, and evidence-based prescribing while promoting affordability and appropriate utilization of medications.

Purpose of the Formulary

The formulary serves as a clinical and administrative guide for providers when selecting medications for members. It reflects medications that are approved for coverage based on clinical efficacy, safety, and regulatory requirements.

• Promotes consistent, evidence-based prescribing
• Supports cost-effective medication management
• Ensures compliance with CMS and payer requirements
• Encourages appropriate utilization of covered medications

Formulary Structure

Medications within the formulary are organized by therapeutic class and may be assigned to different coverage tiers. Tier placement may impact member cost-sharing and coverage requirements.

• Tier Levels: May include preferred, non-preferred, or specialty tiers
• Generic vs. Brand: Generic alternatives are encouraged when available
• Specialty Medications: Certain drugs may require specialty pharmacy handling

Coverage Requirements

Some medications may have utilization management requirements to ensure appropriate use. These requirements are designed to align treatment with clinical guidelines and patient safety standards.

• Prior Authorization (PA)
• Step Therapy
• Quantity Limits

Providers should review formulary requirements prior to prescribing and submit any required documentation to avoid delays in treatment.

Formulary Updates

The Drug Formulary is reviewed and updated periodically to reflect new clinical evidence, regulatory changes, and medication availability. Updates may include additions, removals, or changes in tier placement or coverage requirements.

Providers are encouraged to review the most current version of the formulary and check for updates regularly.

Questions or Assistance

For questions regarding drug coverage, prior authorization requirements, or formulary changes, please contact Provider Support or refer to the Provider Resources section of this website.