Formulary (Drug List)
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!
Our list of drugs (formulary) shows the Part D drugs that we cover. In general, we cover your drugs if they are medically necessary. Drugs on our list of drugs are covered when you use our network pharmacies or mail order program for maintenance drugs. Maintenance drugs are drugs you take for a chronic or long-term condition. Some drugs we cover have limits or other rules.
The Pharmacy and Therapeutics Committee, our team of independent healthcare experts, reviews and approves our list of drugs. We don’t include all drugs. Some drugs may not be covered or are excluded. Other drugs are not on the list because of clinical and cost reasons.
How Do I Search for a Drug in the List of Drugs (Formulary)?
You can search for a drug by using the search tool, alphabetical index or by medical condition. There are three ways to find out if your drug is covered.
Search Tool: Open the List of Drugs (PDF). Hold down the “Control” (Ctrl) and “F” keys. When the search box appears, type the name of your drug. Press the “Enter” key.
Alphabetical Index: The index at the end of the PDF lists the names of generic and brand name drugs from A to Z. Once you find a drug name, go to the page number listed to see if the drug is covered.
Medical Condition: The drugs are grouped into categories by type of medical condition that they are used to treat. For example, “Cardiovascular Agents – Drugs to Treat Heart and Circulation Conditions. If you know what your drug is used for look through the list to find the category. Then look under the category for your drug.
You can ask us to make an exception to our rules for your drug(s). To learn how, read your Evidence of Coverage or visit our Plan Materials forms page. When asking for an exception, include a statement from your doctor that supports your request, plus a completed Coverage Determination form.
Generally, we must decide on your request within 72 hours after we get your doctor’s statement. You can ask for a fast (expedited) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours. If we approve your expedited request, we must give you a decision within 24 hours after we get your doctor’s statement.
List of Drugs Change Notice
Drugs may be added or removed from our list of drugs during the year. We will tell you 60 days before the following changes are made to the list of drugs:
- Remove a drug from the list.
- Change drug requirements.
- Move a drug to a higher cost sharing tier.
If the Food and Drug Administration (FDA) or the drug’s maker says a drug is not safe, it will be removed from our list of drugs right away.
- HMO List of Drugs Change Notice – Coming Soon
- HMO SNP List of Drugs Change Notice – Coming Soon