About Our Drug Formulary
A drug formulary is a list of medications that are usually covered under a member's medical coverage agreement. Formularies exist to allow health care providers to offer the most effective drug therapy possible with limited resources in today's environment of increasing drug prices. Having a formulary allows us to offer the safest, most effective, and least costly health care possible.
How We Develop Our Formulary
The Pharmacy and Therapeutics Committee (P&T Committee) develops our drug formulary. This committee, composed of physicians from various medical specialties, reviews the medications in all therapeutic categories based on safety, effectiveness, and cost, and selects the most cost-effective drugs in each class.
The P&T Committee regularly reviews new and existing medications to ensure that our formulary remains responsive to the needs of our members and providers. We update the formulary periodically and it is subject to change.
Health Plan Coverage for Drugs
Many of our Group Health, Options, and Alliant health plans cover certain prescription drugs, but we do not cover all medications in the formulary. Coverage for certain medications is subject to an individual member's medical coverage agreement. If you have questions about whether we will cover a prescription, contact Customer Service.
We generally do not cover drugs not in the formulary, although we may cover some under special circumstances. Items that we do not cover include:
Brand Name and Generic Drugs
We list brand names only to serve as a guide; it does not imply coverage of a specific brand. The generic column indicates whether a generic product is available for a drug. We substitute generic drugs when available and allowed by the prescriber. When a generic is available, we consider the brand medication nonformulary and subject to higher cost shares.
When a company identifies a drug in the laboratory, that company is granted a patent on the drug for a period of 20 years. During the life of the patent, no other manufacturer is allowed to produce or sell the same drug product without the patent-holder's approval, thus eliminating direct price competition. Patent protection allows the original drug company to recoup the money it spent research and marketing and to make a profit.
After the patent expires, other pharmaceutical manufacturers may develop, test, and market the same drug. These identical products, called generic, contain exact quantities of the same active ingredient in the same dosage form as the innovator's product. We have significantly reduced total drug expenditures without compromising quality by using generic drugs. This strategy has resulted in savings to you in the form of lower rates and prescription prices.
Prior authorization is a process by which a provider must obtain prior approval for coverage of a formulary medication. The P&T Committee determines criteria that must be met in order for a patient's health plan to cover a drug. These medications are most often drugs with safety issues or with a high potential for inappropriate use. These medications also usually have lower-priced clinical alternatives. Prescribers do not need authorization to prescribe the drug, only to determine coverage for a patient.
We do not cover medications not listed in the formulary unless approved by the health plan as medically necessary. You or your doctor can request an exception to prescribe nonformulary medications using the form below, and your request will be reviewed by our pharmacy staff. In most cases, there is a formulary alternative your doctor can use. If we do not approve the medical exception and you still choose to get the nonformulary prescription, then you are responsible for the full cost of the drug.
To request a paper copy of the Group Health drug formulary, contact Pharmacy Administration at 206-901-4400.