Yes, each medical plan has a different pharmacy benefit manager. 

To find out more about the network of pharmacies, covered drugs, and transition of care available under each plan, visit the plan website or contact the plan directly.

 

A formulary, sometimes called a recommended drug list, is a list of preferred generic and brand name drugs.  This list includes a wide selection of medications and offers you a choice while helping keep the cost of your prescription drug benefits affordable.

Every drug on the formulary has been approved by the Food and Drug Administration (FDA) and reviewed by an independent group of doctors and pharmacists for safety and efficacy. The list can be obtained by contacting each plan directly.

 

The Primary/Preferred Drug List is a list of commonly prescribed drugs in select drug classes, or a grouping of drugs that are used to treat the same condition.  There are preferred brand drugs as well as preferred generic drugs on the drug list.  The preferred drugs listed are considered preferred drug choices as they provide the greatest economic value in the drug class.

It is important to note that preferred medications are not chosen for inclusion on the Primary/Preferred Drug List based on price alone.  They are selected based on comparable clinical efficacy to other products in the same drug classes.

The Primary/Preferred Drug List is reviewed and updated on a quarterly basis.  Medical specialists (physicians and pharmacists) conduct a rigorous clinical and economic review and evaluate any proposed changes to ensure they are consistent with the most recent and relevant clinical findings.

 

Maintenance medication is one that you take on a daily and ongoing basis to maintain your health and no dosage changes are required for the most part.  Examples of this type of medication are those that you take to manage blood pressure or cholesterol.

 

Prior authorization is a patient safety process that ensures members get the safest medications, approved by the Food and Drug Administration (FDA), with the best value.  Medications selected for prior authorization meet at least one of the following criteria.

  • Have a high potential for abuse
  • Require laboratory tests/monitoring for safety reasons
  • Are part of a step-care guideline
  • Are used for indications not approved by the FDA or the plan
  • Have a high potential for "off-label" or experimental use
  • Are excluded or limited by benefit coverage

 

The pharmacy will let you know if additional information is required.  You or the pharmacy can then ask your doctor to call a special toll-free number.  This call will initiate a review that typically takes one to three business days.  This is a common practice for pharmacies and physicians.

For more information, please contact the plan directly.

 

There may be limitations on filling prescriptions at non- participating pharmacies for some plans.  For example, you may only be able to receive reimbursement for drugs purchased at non-participating pharmacies in the event of an emergency or urgent situation or when you are traveling.

Check with the plan directly to determine any limitations.

 

To view related documents, please visit the "Prescription Coverage" section of the Forms and Publications page.