Lowest Net Cost Formulary
Most of our plans use the Lowest Net Cost Formulary. The Lowest Net Cost Formulary is a list of prescription drugs that an independent panel of doctors and pharmacists has chosen because they work well to treat your condition. They are also cost-effective. Drugs on the Lowest Net Cost Formulary will cost you less out of pocket than those not on the list. You and your doctor, however, have the freedom to choose the medication that works best for you.
Excluded Drug List
This is a list of drugs that are excluded from coverage, as well as how to request a formulary exception for an excluded drug.
$0 Covered Drug List
Under Health Care Reform, the Affordable Care Act (ACA) requires most health plans to cover certain drugs at $0 cost to members. View the $0 Covered Drug List.
Drug Management Programs
Not all members have all four of these programs. Please check your Schedule of Benefits to find out which ones apply to you.
Most of our members need prior authorization for certain drugs. Learn how the Prior Authorization Program works.
This program limits the amount of certain drugs your plan will cover. Learn how the Quantity Management Program works and which drugs are included in the program.
This program makes sure members get quality, cost-effective drug therapy. It groups drugs into two categories. Members must try one or more Step One Drugs before their plans will cover Step Two Drugs. Learn how the Step Therapy Program works and which drugs are included in the program.
Specialty drugs are prescription medications that are used to treat complex or chronic medical conditions like cancer, rheumatoid arthritis, multiple sclerosis and hepatitis, just to name a few. Depending on your plan, you may pay a different copayment or coinsurance for drugs on the Specialty Drug List.
Some members are subject to separate management programs for specialty drugs that are covered under their medical benefits.
Specialty Drug Medical Benefit Programs
Specialty drugs are prescription medications that are used to treat complex or chronic medical conditions like cancer, rheumatoid arthritis, multiple sclerosis and hepatitis, just to name a few. Many groups have implemented programs designed to manage the use of these drugs through the medical benefit.
Certain self-administered specialty drugs are only covered under the pharmacy benefit. Learn how the Self-Administered Drug program works and which drugs are included.
Medical Drug List
Most benefit plans include medical drug management, including prior authorization. Check your plan materials to see if this information applies to you. This list may change or expand from time to time without prior notice. Drugs on the Medical Drug List may require prior authorization (PA) under the medical benefit through our Specialty Medical Benefit Management (SMBM) program.