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What is a formulary or a drug list?

A drug list, also called a formulary, is a list of generic and brand-name drugs covered by a health plan. Although a drug may be on the formulary drug list, it might not be covered under your plan. Review your plan’s certificate of coverage or other plan materials for details on your benefits.

How are drugs selected for the formulary/drug list?

An independent group of pharmacists and doctors, called the Pharmacy and Therapeutics Committee, reviews available drugs on an ongoing basis and then selects those considered “best choices.” They review scientific literature and reports, consult with other health care professionals and use their own expertise to make decisions.

Before a drug is included in the drug list, it must pass a strict review by the committee, based on these criteria:

  • Safety: it must be approved by the U.S. Food and Drug Administration (FDA).
  • Efficacy: it must be effective in treating a disease or symptoms with few side effects.
  • Uniqueness: the new drug must offer unique qualities compared to existing drugs in the drug list.
  • Cost: the new drug must demonstrate a positive impact on total health care costs.

Lower-cost drugs are preferred. Often, there are many drugs available to treat the same condition. In some cases, two drugs are the same in effectiveness and safety. In this case, the drug included on the drug list will be the lower-cost drug. CCStpa negotiates discounts on behalf of our members. We pass these savings on to you by holding down drug coverage costs.

Remember, not all benefit plans are subject to the drug list. Check your plan’s certificate of coverage or other plan information for benefit details.

What is a generic?

A generic drug is manufactured and sold by a company other than the company that originally made it. For example, the company that developed acetaminophen gave it the brand name Tylenol. When the patent expired, other companies started to make the generic version. Although generic drugs are chemically the same as brand-name drugs, they are typically sold for much less money than the brand-name drug.

Not all brand-name drugs have a generic version available. That’s why it’s important to ask your doctor. If there is a generic available, your doctor can prescribe it instead of the brand-name drug. Sometimes your doctor may feel the brand-name drug is the most appropriate for you. Talk with your doctor to find out what’s best for you.

What is a mandatory generic penalty?

If you choose to get a brand-name drug when an equivalent generic drug is available, you also have to pay the difference in cost between the brand-name and the generic drug and any coinsurance and/or deductible that applies. When you reach your out-of-pocket maximum, you would still pay the difference in cost between the brand-name and the generic drug, even though you are no longer responsible for coinsurance and deductible.

Can a mail service pharmacy receive faxed prescriptions?

Yes, you can provide your doctor with a physician fax form so that he/she can send your prescription directly to the mail service pharmacy for you. Prescriptions faxed for controlled substances will not be processed. You must mail the original prescription signed by your doctor to the mail service pharmacy.

How much will I pay at the pharmacy?

Check your plan’s certificate of coverage or other plan information for benefit details.

Why is Adderall XR covered but not amphetamine / dextroamphetamine extended release (ER)?

Sometimes the exact same drug is sold using different names. This can happen with branded or generic drugs. A drug company may decide to label a drug with only the generic name, even if they did not seek FDA approval for the drug as a generic. This means even though the drug may have a generic name, it is not recognized as a generic and will not be covered as one. Generally speaking, these products are not on our formulary or we may decide to cover only one of the versions.

Who do I contact if I have questions?

Ask your doctor if you have questions or concerns about drugs you are taking. He or she can tell you what is most appropriate for you.

If you have questions about your drug benefits, call customer service at the number on the back of your member ID card.