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Understanding Your Prescription Drug Coverage (Formulary)

Our formulary is the list of medications that are covered under our pharmacy benefit plans. We offer a variety of benefit designs, ranging from 3 to 6 tiers. How much you pay – your cost share – depends on which formulary design is included in your benefit plan and which tier your medication is in. In 2017, we added new benefit designs to help employers and members manage their prescription drug costs.

We have made some changes to our list of covered medications (formulary) for 2017. The new formulary offers greater flexibility for consumers to choose lower cost, comparable alternatives to high-cost brand and generic drugs. We encourage you to review the 2017 list to see if any medications you might be taking have changed status.

Changes During a Plan Year

As new drugs and drug formulas become available, we evaluate them and update the formulary to get safer, more effective and valuable medications in members’ hands.

While most drugs will not change cost tiers during a benefit year, they may change if one of the following situations occur:

  • The same drug becomes available as a generic.
  • Safety or effectiveness concerns are raised.
  • We determine that changes to all of our benefit designs would overall be best for our members.

Finding Your Pharmacy Coverage (Formulary)

Your pharmacy coverage depends on which plan design you have.  To find out which formulary design applies to your plan, please see your plan benefits booklet. Our formularies are listed below, along with a brief description, examples of corresponding health plans and group sizes that typically use that design.

Preferred Medication List (PML)

This 3-tier formulary design is typically used by mid-size employer groups (51-99 Employees) and large employer groups (100+ Employees), as well as some individual members and their families or small employers. If your plan is considered a “Grandfathered” or “Grandmothered” plan, the Preferred Medication List applies. 

Examples of health plans using the Preferred Medication List:

  • Innova
  • Engage
  • HSA 2.0
  • HSA 3.0

Essential 4 Tier Formulary

This 4-tier formulary design is typically used by individual plan members and their families, or by small employer groups (up to 50 employees). This includes plans sold within the State or Federal Marketplaces.

Note: Some Small Groups (up to 50 employees) use the Essential 4-Tier Formulary and others use the Essential 6-Tier Formulary. We have created a list of all Groups Using the Essential 4-Tier Formulary. You can search for your group ID number on this PDF to see if your group uses the Essential 4-Tier Formulary. (If your Group ID number is not on this list, then your group is not using the Essential 4-Tier formulary design.)

    Examples of health plans using the Essential Formulary:

  • 2016 Individual On & Off Exchange Metallics
  • 2016 Small Group Direct Metallics

Essential 6-Tier Formulary

This 6-tier formulary design is typically used by individual plan members and their families, or by small employer groups (up to 50 employees). This includes plans sold within the State or Federal Marketplaces.           

Examples of health plans using the Essential 6-Tier Formulary:

  • Individual On & Off Exchange Metallics
  • Small Group Direct Metallics

Oregon Standard Formulary

This 4-tier formulary design is typically used by individual plan members and their families in certain parts of Oregon, or to small employer groups (up to 50 Employees).  This includes plans sold within the State Marketplace. 

Examples of health plans using the Oregon Standard Formulary:

  • 2016 Individual Standard On & Off Exchange
  • 2016 Group Standard Direct

 

Smart Choice Formulary

This 6-tier formulary design is typically used by mid-size employer groups (51-99 Employees) and large employer groups (100+ Employees).

Classic Formulary

This 4-tier formulary design is typically used by small employer groups (up to 50 employees).

Links to Formulary Pages

 

Preferred Medication List (PML)

Oregon, Idaho, Washington & Utah Plans

 

Essential Formulary  (4 tier)

Idaho, Oregon & Utah Plans

 

Essential Formulary (4 tier)

Washington Plans

 

Essential Formulary (6 tier)

Oregon, Idaho, Washington & Utah

 

Oregon Standard Formulary

 

Smart Choice Formulary

Oregon, Idaho, Washington & Utah

 

Classic Fomulary

All states - 4 Tier

 

Additional Information

Preventive Medications Coverage

Description of Preventive Medications Coverage

Self Administered Chemotherapy Covered Medications List

List of Chemo drugs considered to be self administered

Self Administered Injectables

Get more information on self injectible medications

Generic Alternatives List

List of Preferred Generics and their Non-Preferred Brand Equivalent

Optimum Value Medications List

List of drugs utilized for common conditions

Alternatives to Non Formulary Medications

A list of medications that can be used as alternatives to medications not covered by our formulary

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