2023 Prime Drug Formulary

Effective Date: January 01, 2023
Date Last Updated: December 31, 2022
Next Revision Date: April 01, 2023

The Universal Rx Outcomes Drug Formulary defines the copayment tier status of the medicines most commonly prescribed. It may not include all drugs covered by your prescription drug benefit and it may include some drugs that are excluded under your particular coverage. For benefit coverage or restrictions please check your benefit plan document(s).

This listing is revised from time to time as new drugs and new prescribing information becomes available.

The coverage tier for each medication has been indicated. Tier 1 medicines require the lowest member copayment. Higher tier medicines require greater member copayment. If a brand name drug does not appear on the list it is assigned the highest copay.

It is recommended that you have this list of medications available when you are with your physician, and a prescription drug is going to be part of the treatment for a clinical condition.

Note: If your plan of benefit includes Prior Authorization for Specialty Drugs, Compound Drugs and/or Fixed Dose Combination Drugs, the following information is important to understand:

Prior authorization may be needed for certain Prescription Drugs to make sure proper use and guidelines for Prescription Drug coverage are followed. We or the Administrator will contact Your Provider to get the details they need to decide if prior authorization should be given. We or the Administrator will give the results of our decision to both You and Your Provider. The prior authorization process is also used to approve requests from Your Provider for contraceptive methods that are Medically Necessary for You based on Your medical or personal history.

Prior authorization procedures and requirements for coverage are based on clinical need and therapeutic rationale. Administration of the prior authorization process considers the desired outcome for the patient, the design of the drug benefit, the value to Us, and all statutory and regulatory requirements. The process offers the prescriber an opportunity to justify the therapeutic basis for the prescribed medication and receive information concerning the acceptance and payment of claims for a particular drug.

You may need to try a Drug other than the one originally prescribed if We determine that it should be clinically effective for You. However, if We determine through the prior authorization process that the Drug originally prescribed is Medically Necessary, You will be provided the Drug originally requested at the applicable Copayment. If approved, Drugs requiring prior authorization will be provided to You after You make the required Copayment. (If, when You first become enrolled, You are already being treated for a medical condition with a Drug that has been appropriately prescribed and is considered safe and effective for Your medical condition and You underwent a prior authorization process under a prior Plan which required You to take different Drugs, We will not require You to try a Drug other than the one You are currently taking.)

The prior authorization review process is outlined below:

  1. A rejected Prescription Drug claim will initiate a request for prior authorization with a request for patient demographic and necessary clinical data of the practitioner licensed to prescribe.
  2. Our Pharmacy Benefit Manager (PBM) reviews available data and determines:
    • Information provided is sufficient to make a determination
    • Information provided is insufficient to make a determination and initiates fax request for necessary clinical data to prescribing practitioner within 24 hours following receipt of review request.
  3. Review of historic medication claim data, standard clinical references and clinical data/information received from the practitioner licensed to prescribe.
  4. Match of available data and information with labeled indication(s) for prescribed medication requiring authorization and against generally accepted clinical authorization criteria
  5. A recommendation to accept claims for payment will be made in writing and provided to Us and removal of Prior Authorization criteria in the Rx claim system will be completed.
  6. A recommendation to not accept claims for payment will be made in writing and provided to Us and will be provided to the practitioner licensed to prescribe, the Prescription Drug claims processor and the Covered Person.
  7. Review and recommendation to be completed within 48 hours following receipt of clinical data from practitioner.

If prior authorization is denied You have the right to file a grievance as outlined in the part WHEN YOU HAVE A COMPLAINT OR APPEAL.

To see if your plan requires prior authorization, please refer to the Prescription Drug benefit section of your certificate of coverage. For a list of Drugs that need prior authorization, please call the telephone number listed on Your ID Card or see the attached Formulary List. The list will be reviewed and updated from time to time. Including a Drug or related item on the list does not promise coverage under Your Prescription Drug coverage. Your Provider may check with us to verify Drug coverage, to find out whether any quantity (amount) and/or age limits apply, and to find out which drugs are covered under the Prescription Drug coverage.

Definitions:

Generic Prescription Drug (Generic) is a pharmaceutical equivalent of one or more Brand Name Drugs and must be approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength and effectiveness as the Brand Name Drug. Generally Generic Prescription Drugs are covered under as a Tier 1 drug.

Preferred Brand Name Prescription Drug (Brand Name) is a Prescription Drug that has been patented and is only produced by one manufacturer. These drugs are generally covered as a Tier 2 drug.

A Non-preferred Brand Name Prescription Drug is one not included on the Plan's formulary or list of preferred prescriptions. Nonpreferred Brand Name Prescription Drugs have a higher coinsurance than Preferred Brand Name Prescription Drugs. You pay more if You use non-preferred drugs than if You opt for Generics and Brand Name Prescription Drugs. These drugs are generally covered as a Tier 3 drug.

Specialty Drugs are "bioengineered" oral or injectable medicines that target and treat complex medical conditions including: blood disorders, cancers, Infertility, hormone or enzyme deficiencies, multiple sclerosis, rheumatoid arthritis, and a growing list of obscure or "orphan" diagnoses. Specialty drugs are complex compounds and some have unique "handling" requirements. The FDA in selected situations has required dispensing from a single Pharmacy or a limited set of "approved" pharmacies. Some "specialty" drugs are oral tablets or capsules while others require injection.

Mail Order Prescription Drug Program

Prescription drugs are available through GeoBlue both for delivery inside the United States as well as outside the United States. If you reside within the United States, the prescription mail order program is available through Elixir Pharmacy. If you reside outside of the United States, the prescription drug mail order program is through Expatriate Prescription Services. Visit the "Prescription Benefits" section of the Member Hub for order instructions. You can also contact our customer service department available toll-free at 1.855.282.3517 or by email to customerservice@geo-blue.com for inquiries about the prescription drug mail order program.

Key to Notations/Special Instructions Found in the Formulary List:

PA: Your plan may require authorization or documentation of previous therapy with other similar medications before this medication is covered. If your plan does require prior authorization before dispensing of the drug, you and your prescribing physician will be asked to complete a Pharmacy Services Review Form. This form is located in the GeoBlue Member Hub under the Coverage & Benefits tab, prescription drugs. The form is also available through our customer service department available toll-free at 1.855.282.3517 or by email to customerservice@geo-blue.com.

ST: A step therapy protocol may be in place for this medication. Claims for this medication may be covered based on previous medication history. If prior medication history does not meet clinical guidelines, prior authorization may be required.

QL: Quantity limitations (maximum number of tablets/capsules, etc. per month or year) may be in place for this medication.

SP: Drug is designated as a specialty drug and may be subject to a separate specialty benefit.

INJ: Product is administered via an injectable route of administration and may be subject to a separate benefit.