Are there any restrictions to my formulary?

Some of the prescription drugs on the Healthfirst Medicare Plan formulary have restrictions on when or how they may be accessed. You can look up individual drugs on our formulary and see if any of these restrictions apply. If you prefer, you can look on the lists available below that show all of the drugs on our formulary that require prior authorization, quantity limits, or step therapy.

Prior Authorization
This means that your provider will need to contact us before you fill your prescription. If we don’t get the necessary information to satisfy the prior authorization, we may not cover the drug.

Drugs covered under Medicare Part B or D
Some drugs may be covered under Medicare Part B or D depending upon the circumstances.  Information may need to be submitted describing the use and setting of the drug to make the determination.

> Download a full list of drugs that require prior authorization

Quantity Limits

This means that we limit the quantity of the drug we will cover.

The symbol (QL, units/days supply) in the Notes column indicates that quantities dispensed may be limited.  The quantity allowed is listed following the QL symbol and may be read as “units per days supply.”

For example, on page 49 the drug NEXIUM 2 is listed with the symbol QL (30 ea / 30 days). This means that this drugs availability is limited to a quantity of 30 per 30 days supply of the drug.  

If your prescription for any of these medications exceeds the maximum quantity listed, you and your doctor will need to request a formulary exception.

The list of drugs that require quantity limits is found on the current formulary.

View your full Medicare formulary here

Step Therapy

In some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition.  

For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.

> Download a full list of drugs that require step therapy