A Healthy CollaborationSM

Restrictions to our Formulary

For certain prescription drugs, PrescribaRxSM has additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and pharmacists developed these requirements and limits for PrescribaRx to help us to provide quality care to our members.

Examples of utilization management tools include:

  • Prior Authorization: PrescribaRx requires you to get prior authorization for certain drugs. This means that you will need to get approval from PrescribaRx before you fill your prescription. If you don’t get approval, PrescribaRx may not cover the drug.
  • Quantity Limit: For certain drugs, PrescribaRx limits the amount of the drug that we will cover per prescription or for a defined period of time. For example, PrescribaRx will provide up to 10 capsules per prescription of TAMIFLU.
  • Step Therapy: In some cases, PrescribaRx requires you to first try one drug to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, PrescribaRx may require your doctor to prescribe Drug A first. If Drug A does not work for you, only then will PrescribaRx cover Drug B.
  • Generic Substitution: When there is a generic version of a brand-name drug available, PrescribaRx network pharmacies will typically give you the equivalent generic version to save you expense unless your doctor has told us that you must take the brand-name drug.
  • Therapeutic Substitution: When there is a therapeutic alternative to treat your condition, your pharmacist or PrescribaRx Plan may contact your doctor to see if the alternative drug is appropriate for you. Only your doctor can authorize this change.

Learning if your drug has restrictions
You can find out if your drug is subject to these additional requirements or limits by looking in the PrescribaRx Searchable Formulary. If your drug does have these additional restrictions or limits, you can ask PrescribaRx to make an exception to our coverage rules.

 

S5597_S5825_C0008_09P0043_v2 (09/2009) Last updated: 09/09/2022

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