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Select a question about Priority Health approved drug lists, also called formularies, from the list below.
Q: What is a formulary? A formulary, also called the "approved drug list," is a list of brand-name and generic drugs that can be prescribed for members who have prescription drug coverage. Sometimes there are limitations to the coverage of a drug; the formulary should explain any of these limitations or conditions of coverage. Q: Why aren't all drugs in the formulary? Drugs are approved for the Priority Health formulary when they are safe, effective, accepted by the majority of physicians in our area, and reasonably cost-effective. If there are drugs in a category that have similar clinical value but are more costly, they are not usually included in the formulary. Drugs that are brand-new on the market are not included in the formulary until the Priority Health committee reviews them at one of its regularly scheduled meetings. Q: Who decides what drugs are included? Local physicians, pharmacists, and health care professionals from Priority Health make the decisions based on studies of what works best. Q: Why do some drugs get included for coverage, while similar drugs do not? Many factors influence the decision. For example, suppose there are two different drugs that are equally safe and efficient, but one must be taken four times a day, while the other can be taken once a day. The once-a-day drug may be the better choice because patients are more likely to take all the doses at the right time. A drug may not be included if the available scientific information is insufficient to determine its clinical effectiveness, or if the drug is judged to offer no clinical or cost advantage over existing comparable formulary drugs. Q: What is a generic drug? A generic drug has only a chemical name, as opposed to a brand name. Every drug is given a generic name to describe its chemical makeup. A generic equivalent drug is a chemical copy of the original brand-name drug. There are also generic alternative drugs, which are not chemically identical but which treat the same disease or condition. Q: Are generic drugs safe? Yes. Like brand-name drugs, they are approved by the Food and Drug Administration (FDA). To gain approval, generic equivalents must contain the same active ingredients and be identical in strength, dosage form (tablet, solution, etc.) and method by which they are taken (by mouth, by injection, applied to the skin, etc.). Q: How often does the Priority Health formulary change, and how often is this website updated? Our committee holds regular meetings to make sure the best drugs are available for our members. Typically, meetings are held once every three months. The formulary and this website are updated based on the outcome of these meetings. Drugs that are added to or removed from the formulary are announced in our member, employer and provider newsletters: Health Journal, Priority at Work, and Pharmaceuticus. Q: What if I join Priority Health, and a drug I take every day is not on the formulary? You'll need to work with your doctor to either find an alternative drug that is on the approved drug list or get authorization to continue taking your current drug. In the meantime, you may qualify for a one-time "transition fill" of your drug. Learn more about 30-day transition fills. Q: What if my doctor gives me a prescription for a drug that is not on the formulary? If there are no similar or equal drugs on the formulary that will help your condition, your physician can request authorization to prescribe a non-formulary drug. Priority Health will approve or disapprove the request, and notify your physician. You may contact a Customer Service representative for help in getting drugs that are not on the formulary. You can appeal our decisions about covering drugs that are not on the formulary. If you need information about appeal and grievance procedures, check this section of our website. Q: What if I want a drug that isn't authorized? If you choose to take non-formulary drugs that are not authorized by Priority Health, you will need to pay for them yourself. The prescription will not be covered through your pharmacy benefit. Q: If I have to try other drugs first before the one I want, do samples count? For safety reasons, Priority Health requires that all drugs you receive are documented in your records, which means not just the name of the drug but the date it was dispensed to you, the quantity dispensed, and the dosage. This can be documented through the pharmacy claims processing system or, in the case of samples given to you by your doctor, in your doctor's office medical chart or records on the day you received them. If we don't have documentation as described above, Priority Health will not consider the use of samples as a "trial" in determining whether to authorize other drugs for you. Q: Why does Priority Health only cover a certain quantity of my medication? Many times, the manufacturers of drugs, along with the Food and Drug Administration (FDA), recommend usual and maximum dosages for medications. Priority Health's quantity limits follow the recommendations from the drug manufacturer and the FDA to ensure that you are receiving a safe dose and quantity of your drug. Sometimes drugs are available in multiple dosage strengths. For example, a drug may be available in a 10mg, 20mg, and 40mg strength. If the manufacturer of that drug recommends it be given one time daily, Priority Health's quantity limits will allow for one dosage per day. This means that if your doctor wants you to take 40mg per day, Priority Health will cover one 40mg dose per day, but not four 10mg or two 20mg doses per day. Q: Why is cost so important? Pharmaceutical drugs are a major part of overall medical expense. The cost of drugs has grown faster than any other medical area. Sometimes new, more expensive drugs do not work any better than lower-cost drugs. One of our jobs in managing health care is to make sure that you get the drugs that will do the best job. Another is to manage costs, so that we can continue to keep you well. Q: How can I get a copy of Priority Health's pharmacy or formulary policies? To request Priority Health's drug formulary or pharmacy policies and procedures, contact Customer Service, or send us a secure message online requesting the information you want.
Last modified
10/29/09
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