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Formulary management procedures

Our drug formulary is reviewed every month. As newer generic products are approved, we make changes and updates on a regular basis. The formulary lists medications by copay tier. Lower tiers are associated with lower cost share. 

In addition to updating the formulary status of covered drugs, we also modify formulary restrictions are also modified as necessary.

 Here is an update of restrictions and limitations associated with the drug formulary: 

  • Closed formulary: We use a closed formulary. If a drug is not listed on the drug formulary, the product is not covered by the member’s pharmacy benefit. If a non-formulary drug is clinically necessary, an exception to coverage request may be submitted. The prescribing provider should include a medical reason for why formulary options are inappropriate.  
  • Mandatory generic substitution: If a drug is available in a generic version, we may require you to use the generic version. If the generic version of the drug is mandated and you choose to receive the brand, you may be responsible for the highest tier branded copay plus the ingredient cost difference between the brand and generic versions. If your physician requests the branded version, you are only responsible for the highest tier branded copay. 
  • Prior authorization: When a drug requires prior authorization, your physician must receive approval before prescribing the drug. The list of prior authorized drugs and the request forms are available on wellfirsthealth.com. 
  • Step therapy: Step edits are often used to require generic or preferred drug use before using a non-preferred drug. When a step edit is in place, you must try the preferred drugs before receiving approval for the non-preferred drugs. Step edits are completed point-of-service at the pharmacy, and there are no prior authorization requirements.
  • Specialist restrictions: Specialist restrictions limit the prescribing of a drug to a unique specialty. These decisions are based on the indications and uses for the specific drug. 
  • Quantity limits: Quantity limits restrict the supply of drug product that may be dispensed either per prescription or per a specific amount of time. 
  • Specialty pharmacy: If a drug is available or mandated to be dispensed by a specialty pharmacy, the specialty pharmacy designation will be applied.