List of Drugs (Formulary)
The formulary is a list of drugs that are covered by a health insurance plan. The list of drugs are covered as long as the drug is medically necessary. To get the drug covered fill it at a network pharmacy. You can also use the mail order program for maintenance drugs. Some coverage rules must also be followed. Some drugs have limits for coverage.
The drugs on the formulary are chosen by drug plan and health experts.
The drugs are reviewed by a group of doctors and pharmacists who do not work for the plan. This group is called the Pharmacy and Therapeutics Committee.
The formulary does not have all drugs on it.
Some drugs are not a covered benefit or are excluded. Some drugs are not are not qualified for clinical or cost reasons.
The formulary is a list of drugs that are covered by a health 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 drug plan and a team of health care professionals. The formulary drugs are then verified by a Pharmacy and Therapeutics Committee, consisting of independent physicians and pharmacists.
The plan does not cover all prescription drugs. Some drugs are not on the formulary because the law does not allow the plan to cover those drugs. In other cases, we have decided not to include a drug on the formulary. The drugs included on the formulary are believed to be a necessary part of a quality treatment plan.
You can ask Superior STAR+PLUS MMP to make an exception to our coverage rules. For specific types of exceptions that you can ask us to make, please refer to the formulary (link below). When you are requesting an exception you should submit a statement from your doctor supporting your request along with a completed Request for Medicare Prescription Drug Coverage Determination form*.
Formulary Change Notice
Superior STAR+PLUS MMP can add or remove drugs from our list of drugs during the year.
We will tell members 60 days before changes are made to the list of drugs. Changes mean taking drugs off the list. Changing the number of pills per month or moving drugs to a higher cost level are changes.
If a drug is viewed as unsafe by the Food and Drug Administration or the manufacturer of the drug, it will be taken off of our list of drugs right away.
Last Updated: 04/19/2018
Our list of drugs (formulary) shows the drugs we cover. The list includes:
- Medicare Part D drugs
- Some Medicaid covered prescription and over-the-counter drugs and items
In general, we cover drugs if they are medically necessary. Drugs on the 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 the 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?
You can search for a drug by using the search tool, alphabetical index or by medical condition.
Search Tool: Open the drug list (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.
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. To view the changes, open the PDF list below.
If you have questions about our list of drugs, or want the most recent version, contact Member Service. We are here to help.
Last updated: 01/30/2019