2022 Prime Drug Formulary

The Universal Rx Outcomes Drug Formulary defines the copayment tier status of the medicines most commonly prescribed. It may not include all drugs covered by your prescription drug benefit and it may include some drugs that are excluded under your particular coverage. For benefit coverage or restrictions please check your benefit plan document(s).

This listing is revised from time to time as new drugs and new prescribing information becomes available.

The coverage tier for each medication has been indicated. Tier 1 medicines require the lowest member copayment. Higher tier medicines require greater member copayment. If a brand name drug does not appear on the list it is assigned the highest copay.

It is recommended that you have this list of medications available when you are with your physician, and a prescription drug is going to be part of the treatment for a clinical condition.

Definitions:

Generic Prescription Drug (Generic) is a pharmaceutical equivalent of one or more Brand Name Drugs and must be approved by the Food and Drug Administration as meeting the same standards of safety, purity, strength and effectiveness as the Brand Name Drug. Generally Generic Prescription Drugs are covered under as a Tier 1 drug.

Preferred Brand Name Prescription Drug (Brand Name) is a Prescription Drug that has been patented and is only produced by one manufacturer. These drugs are generally covered as a Tier 2 drug.

A Non-preferred Brand Name Prescription Drug is one not included on the Plan's formulary or list of preferred prescriptions. Nonpreferred Brand Name Prescription Drugs have a higher coinsurance than Preferred Brand Name Prescription Drugs. You pay more if You use non-preferred drugs than if You opt for Generics and Brand Name Prescription Drugs. These drugs are generally covered as a Tier 3 drug.

Specialty Drugs are "bioengineered" oral or injectable medicines that target and treat complex medical conditions including: blood disorders, cancers, Infertility, hormone or enzyme deficiencies, multiple sclerosis, rheumatoid arthritis, and a growing list of obscure or "orphan" diagnoses. Specialty drugs are complex compounds and some have unique "handling" requirements. The FDA in selected situations has required dispensing from a single Pharmacy or a limited set of "approved" pharmacies. Some "specialty" drugs are oral tablets or capsules while others require injection.

Key to Notations/Special Instructions Found in the Formulary List:

ST: A step therapy protocol may be in place for this medication. Claims for this medication may be covered based on previous medication history. If prior medication history does not meet clinical guidelines, prior authorization may be required.

QL: Quantity limitations (maximum number of tablets/capsules, etc. per month or year) may be in place for this medication.

SP: Drug is designated as a specialty drug and may be subject to a separate specialty benefit.

INJ: Product is administered via an injectable route of administration and may be subject to a separate benefit.

2022 Prime Drug Formulary