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Coverage and cost


  • What is a drug list/formulary?

    A formulary is a list of drugs covered by your health plan. The list is designed to provide you and your physician with the most safe, effective drugs at the most reasonable cost.

    The drug list is developed by a Pharmacy and Therapeutics (P&T) committee. The P&T committee is made up of a diverse group of doctors and pharmacists. When adding or removing drugs from the drug list, the P&T committee reviews each drug for its safety, effectiveness, uniqueness and cost. This ensures that drugs on the drug list are safe for patients and effective in fighting disease. It can also include drugs that are unique in addressing certain health conditions.

    Health plans use the drug list to provide their members with effective drug therapies at reasonable costs. For this reason, using drugs from a drug list is important for both you and your health plan.

    Often, many drugs are available to treat the same condition. If two drugs are equivalent in effectiveness and safety, the drug list will include the lower cost drug. You're not required to purchase only drugs that appear on your health plan's drug list. However, you may pay more out-of-pocket for a drug that is not on the drug list. You may need to pay the full cost of the drug if it is not covered by your benefit plan.

    Changes in a drug list result from decisions made at P&T committee meetings. The P&T committee meets quarterly to consider changes. These regular meetings ensure that the drug list is kept current. For example, if a new drug is found to be more effective than one already on the drug list, the new drug may replace the less effective drug.

    The process of adding and removing drugs from a drug list ensures that the drug list is kept current and that members receive the most appropriate drug therapies.

    A drug may also be removed from a drug list for safety reasons. The Food and Drug Administration (FDA) tracks drug safety information. The FDA issues reports about side effects, warnings or contraindications. As Prime monitors these reports, this may trigger a change in a drug list.