Drug Lists and Drug Management Programs
The information in this section applies to members of most employer group plans and individual members who have plans they purchased before the Affordable Care Act (ACA) became effective in 2013 (including Personal BlueSM, MSA and Mark IV plans).
Drug Lists
Want to know if a medication is covered? Most plans have guidelines around which medicines they’ll cover and what rules will apply. These lists and programs apply to most members’ prescription benefits.
Preferred Drug List
Most of our plans use the Preferred Drug List (PDL). Doctors and pharmacists developed the PDL based on safety, efficacy and cost-effectiveness. You’ll save money when you use the drugs on this list. Of course, it’s up to you and your doctor to decide which medicines you’ll use.
Try Generics Drug List
Some plans require you to try a generic version of a drug first before the plan will cover a brand name. Even if yours doesn’t, most members save money when they choose generics. So, the Try Generics Drug List can be a useful reference for you and your doctor.
Specialty Drug List
The drugs on the Specialty Drug List treat complex or chronic conditions such as cancer, rheumatoid arthritis, multiple sclerosis and hepatitis, just to name a few. You may pay a different copay or coinsurance for these drugs. And certain rules may apply.
Excluded Drug List
There are some medications that our pharmacy benefits don’t cover. There may be safe, effective, less costly options. View the Excluded Drug List.
$0 Covered Drug List
The Affordable Care Act (ACA) requires most health plans to cover certain drugs at no cost to members. View the $0 Covered Drug List.
Drug Management Programs
Some plans include drug management programs for certain medications. These may include:
Prior Authorization
You must get approval from the health plan before beginning some medications. Learn more about the Prior Authorization Program.
Quantity Management
You can only get a certain quantity of some drugs within a given time frame. There are some exceptions, with prior authorization. Learn more about the Quantity Management Program.
Step Therapy
Step therapy requires you to try more cost-effective options first. There are some exceptions, with prior authorization. Learn more about the Step Therapy Program.
Opioid Management
Opioids are subject to daily quantity limits. You may also need prior authorization for certain situations. Learn more about the Opioid Management Program.
Log into My Health Toolkit® to Review Your Pharmacy Benefits
To see what your specific plan covers, log into My Health Toolkit. Under Benefits, look for Prescription Drugs.