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We cover the prescription medications on the preferred drug list (PDL) with small copays (usually $3 or less). If your patient needs medication, you’ll want to check the list for covered medications, step therapy requirements, quantity limits and updates. You can download the list or check it online.
If a medication isn’t listed on the PDL, you can:
- Prescribe a similar one that’s on the list
- Get prior authorization (PA) for coverage
Still not sure if we cover a specific medication? Just call 1-855-242-0802 (TTY: 711). We can check it for you.
You can also see the list of medications we cover for diabetes supplies.
Members can get coverage for OTC medications on the PDL (PDF) when they:
- Meet any added requirements (for some medications)
- Get a prescription from their provider
- Fill their OTC prescription at a pharmacy in our network
Not sure what’s covered? Just call us at 1-855-242-0802 (TTY: 711). Be sure to have the member’s list of medications ready. We can check to see if they’re on the list.
Members can get $25 per month toward some OTC medications and supplies.
If you prescribe a specialty medication, members can fill it at any pharmacy in our network. Not all pharmacies carry these medications, so members may need to find a specialty pharmacy. Some conditions that need specialty medications include:
- Immune deficiency
- Multiple sclerosis
- Rheumatoid arthritis
You’ll want to get PA for these medications. Fax the PA form to 1-844-699-2889. Or you can call 1-855-232-3596 (TTY: 711) to ask for PA. You can also include any medical records that may help with the review of your request.
More pharmacy info
Learn about everything from step therapy to prior authorization (PA).
When members need medication, they’ll:
- Ask you to make sure the medication is on the PDL
- Take their prescription to a pharmacy in our network
- Show their plan member ID card at the pharmacy
Remind members to check with you at least five days before running out of medication. They understand that you may want to see them before prescribing refills.
The step therapy program requires certain first-line drugs, such as generic drugs or brand-name drugs, to be prescribed before approval of specific, second-line drugs. The PDL identifies these drugs as “STEP.”
Certain drugs on the PDL have quantity limits. The PDL identifies these drugs with the letters “QLL.” Quantity limits are based on:
- FDA-approved dosing levels
- Nationally established, recognized guidelines related to each condition
Need to ask for an override for step therapy or a quantity limit? Just fax the pharmacy PA form to 1-844-699-2889. You can also include any supporting medical records that may help with the review of your request.
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