Pharmacy/Drug Coverage

Standard Pharmacy Plans

Select the correct formulary below:

Custom Premium Drug List

Closed Formulary

This prescription drug list covers benefits for members on commercial plans with a closed PDL formulary.

Drug Lookup

If you are a member, log in to your member website to find accurate information related to your plan.

Additional Resources

Drug-Specific PCGs

RESOURCES
How to Access Drug-Specific PCGs within the Searchable Tools PCG List

General PCGs

RESOURCES
General Medication Coverage Guideline
Non-Formulary Medications Coverage Guideline (for Closed Formularies)
Compound Medication (Standard Plans only)
Benzodiazepine Limitation for Quantity and Dosage
Biologic & Immunological Agents (oral): Cibinqo, Olumiant, Otezla, Rinvoq, Sotyktu, Xeljanz, Xeljanz XR
Brand over Generic Medication Exception
Cost Share Waiver Exception Policy for Preventive Medications
Generic Statin Medications for Prevention Benefit Coverage with Waived Cost Share
Medications Which Contain Simvastatin 80mg
Medication Limitation for Age, Gender, Quantity & Dosage
Off-Label Use of Cancer Medications
Off-Label Use of Non-Cancer Medications
Opioid Limitation for Quantity and Dosage
Step Therapy

PCGs for Drugs and Devices that may be covered under the Medical Benefit

RESOURCES
Benlysta
Biologic & Immunological Agents (injection): Actemra, Amjevita, Cimzia, Cosentyx, Enbrel, Humira, Kevzara, Kineret, Orencia, Siliq, Simponi, Simponi Aria, Akyrizi, Stelara, Tatlz, Tremfya
Biosimilar Step Therapy
Continuous Glucose Monitoring (CGM) Devices: Dexcom, Freestyle Libre, Medtronic, Senseonics Eversense
Fensolvi, Lupron Depot, Lupron Depot PED
Hereditary Angioedema Medication Therapy: Berinert, Cinryze, Firazyr, Haegarda, Icatibant Acetate, Orladeyo, Ruconest, Sajazir, Takhzyro
Insulin Pumps: Insulet - Omnipod/Omnipod Dash/Omnipod 5 G6, Medtronic MiniMed - 630G/670G/770G, Tandem - T:Slim X2
Octreotide Products: Mycapssa, Octreotide Acetate, Sandostatin, Sandostatin LAR Depot
Sunlenca

Haven’t found what you need? We can help.

1-866-325-1794

Legal Disclaimer: Information provided is subject to all terms, conditions, limitations, and exclusions of your benefit plan. In the event of any discrepancy, the claims adjudication system and your benefit plan take precedence.