A formulary is a list of all the drugs that are covered by an insurance plan. In general, the drugs listed in the formulary are covered as long as the drug is medically necessary, the prescription is filled through a network pharmacy or network mail order facility (when applicable), and other coverage rules are followed. For some drugs, there may be additional requirements or limits to coverage.
The drugs on the formulary are selected by the plan and a team of health care professionals. The formulary drugs are then reviewed and approved by the Pharmacy and Therapeutics Committee, consisting mostly of independent physicians and pharmacists.
Not all drugs are included on the plan formulary. In some cases, drugs are excluded from benefit coverage. In other instances, a combination of clinical and economic criteria was used to decide not to include a particular drug on the plan formulary. The drugs on the formulary are believed to be a necessary part of a quality treatment plan.
You can ask us to make an exception to our coverage rules. For specific types of exceptions, please refer to your Evidence of Coverage. When you are requesting a formulary and/or tiering exception you should submit a statement from your doctor supporting your request along with a completed Request for Medicare Prescription Drug Coverage Determination.
Generally, we must make our decision within 72 hours of getting your prescriber’s or prescribing doctor’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s or prescribing doctor’s supporting statement.
Please see the Coverage Determinations, Exceptions and Redeterminations page for more details.
Formulary Change Notice
Allwell may add or remove drugs from our formulary during the year. If we remove or change Part D drugs from our formulary, add prior authorization or quantity limits on a drug and/or move a drug to a higher cost-sharing tier, we will notify members and providers of the change at least 60 days before the date that the change becomes effective. However, if the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary. You can view any changes that have been made to the 2018 Prescription Drug Formulary by clicking on the below link.
If you have questions about our formulary or want to get the most recent list of drugs, call us. We are here to help!
Look at 2018 information for plan details.