FORMULARY

In addition to filling your prescriptions at one of our conveniently located contracted pharmacies, you may use our Plan’s mail-order service to fill prescriptions for any drug on the formulary list.

You may use our network mail-order-pharmacy service to fill prescriptions for all formulary medications. 

When you order prescription drugs through our network mail-order-pharmacy service, you must order at least a 30-day supply, and no more than a 90-day supply of the drug. Generally, it takes the mail-order pharmacy 14 days to process your order and ship it to you.  However, sometimes your mail-order may be delayed. If you prescription will take longer than 14 days to process, you may contact Customer Services to obtain approval for a local pharmacy refill.

You are not required to use our mail-order services to get an extended supply of mail-order drugs. You can also get an extended supply through all retail network pharmacies. Some retail pharmacies may agree to accept the mail-order co-payment or coinsurance for an extended supply of medications, for which you may not have to pay additional costs.  Other retail pharmacies may provide an extended supply, but charge a higher co-payment or coinsurance than our mail-order service.  Please call Customer Services to find out which retail pharmacies offer an extended supply.

FILLING PRESCRIPTIONS OUTSIDE THE NETWORK

We have network pharmacies outside of the service area where you can get your drugs covered as a member of our Plan. Generally, we only cover drugs filled at an out-of-network pharmacy in limited circumstances when a network pharmacy is not available.  Below are some circumstances when we would cover prescriptions filled at an out-of-network pharmacy.  Before you fill your prescription in these situations, call Customer Services to see if there is a network pharmacy in your area where you can fill your prescription.  If you do go to an out-of-network pharmacy for the reasons listed below, you may have to pay the full cost (rather than paying just your co-payment) when you fill your prescription.  You may ask us to reimburse you for our share of the cost by submitting a claim form.  You should submit a claim to us if you fill a prescription at an out-of-network pharmacy, as any amount you pay will help you qualify for catastrophic coverage. 

Note:  If we do pay for the drugs you get at an out-of-network pharmacy, you may still pay more for your drugs than what you would have paid if you had gone to an in-network pharmacy.

Easy Choice Health Plan (HMO) will cover 3 day fills for prescriptions out of network on an emergent/urgent basis. Please contact Customer Services for additional information.

2010 Benefit Year:

2010 Formulary - Easy Choice Health Plan (HMO)’s Comprehensive Formulary (English/Spanish). (Download PDF)

2010 Notice of Formulary Changes (Download PDF)

2010 Step Therapy Requirements (Download PDF)

2010 Prior Authorization Criteria*(Download PDF)

* Prior Authorization Criteria

Certain medications on Easy Choice Health Plan (HMO)’s formulary must be reviewed by physicians and pharmacists in order to be prescribed to our members. This process is called prior authorization.

There are certain criteria that must be met in order for the medication to be approved. Prescribing physicians should request authorization only when the criteria for that specific medication are met.

Below is a list of formulary medications that require prior authorization. Simply click on the Prior Authorization Criteria link to view the applicable authorization requirements.

Over-the-Counter (OTC) drugs are covered within Tier 0 with $0 copay includes: Loratadine, Loratadine D, Cetirizine, Cetirizine D, Ketotifen OTC, Omperazole under Part D benefit.

(Download PDF)
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