Generally, if you are taking a drug on our current formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the current coverage year except when a new, less expensive generic drug becomes available, or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year.
Formulary changes happen from time to time if drugs are:
- Recalled from the market;
- Replaced by a new generic drug; or,
- Clinical restrictions are added, including, but not limited to, prior authorization, quantity limits or step therapy.
If we remove drugs from our formulary or add prior authorization, quantity limits and/or step therapy restrictions to a drug, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes it from the market, we will immediately remove the drug from our formulary and provide notice to members who take it.
If a drug that you use is on our list of changes, please contact your provider to discuss possible alternatives. If there is not another appropriate drug on our formulary that could treat your condition, you have the right to request a formulary exception.
See the Coverage Determinations and Exceptions section for more information.