Affordable Care Act Plans: 2023 Formulary for AdvanceHealth, Cultivate, EverydayHealth, Individual PPO, and TrueHealth Plans
This formulary applies to Affordable Care Act (ACA) closed formulary plans, including Qualified Health Plans (QHP).
The prescription drug benefit information provided through the use of this website is subject to all terms, conditions, limitations and exclusions of the member's plan. Please consult the Summary of Benefits for a complete description of the prescription drug benefit. In the event of a discrepancy between information provided on this website and the benefit plan booklet, the terms of the benefit plan apply.
To see drug-specific pharmacy coverage guidelines (PCGs), search for a drug name in the searchable tool, or download the PCG list below.
View "How-to" Guide for easy instructions for using this tool!
Frequently Asked Questions
Certain medications require approval prior to being obtained through your pharmacy benefits. This process is called prior authorization. A prior authorization request must be submitted and signed by your provider. Request forms are found at azblue.com. Click on the Resource Center tab, select Pharmacy, then select View resources for Standard Pharmacy Plans. The Pharmacy Prior Authorization Request Form is listed under the Forms and Resources section of the page.
Prior authorization requests are reviewed within 10 business days for standard requests. Requests noted by your provider as urgent are reviewed with request will be reviewed within 24 hours. An exigent request requires a written statement from the prescriber, explaining the reason for exigency.
The BCBSAZ Pharmacy and Therapeutics (P&T) Committee creates PCGs, which take into consideration the medical literature. The guideline may state specific limitations, including dosing, gender limits, age limits, or FDA indications for use. If the application of a guideline results in a non-covered claim, the provider has the option to appeal the decision.
Additional information about your pharmacy benefits can be found on azblue.com under Forms and Resources & PCG sections. This includes:
- Pharmacy Coverage Guidelines
- Prior Authorization Request Form
- Mail Order Enrollment Forms
- Prescription Medication Reimbursement information
Coverage may be limited to specific quantities per prescription and/or time period based on FDA recommendations. Coverage may also be stricter for controlled substances. If a medication is above quantity limits, it will reject at the pharmacy; your provider may request Prior Authorization.
Step therapy is a limitation that requires you to try preferred medications before the plan will pay for another medication for the same medical condition that the doctor may have originally prescribed. An automated, electronic review of your medication history is performed to determine whether other medications have been tried first for your condition. This ensures clinically sound and cost-effective treatment options are tried. If a prescribed medication does not meet the step therapy criteria, it may not be covered. You should consult with your doctor about alternative therapy. If a medication does not meet the step therapy criteria for automatic approval, it will reject at the pharmacy; your provider may request prior authorization.
Coverage may be limited to specific patient age(s) based on recommendations by the Food and Drug Administration (FDA). If a medication is outside of age limits, it will reject at the pharmacy; your provider may request Prior Authorization.