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About the Formulary

We may add or remove drugs from our formulary during the year. If we remove drugs, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify members who take the drug of the change at least 60 days before the change becomes effective (or when a member requests a refill). These are recent changes to the formulary.

Abridged Formulary (List of Covered Drugs) Correction

Please note that this booklet has an error with the page numbers listed in the Index at the end. When you reference the Index, subtract one from the listed page number.

For example, if you look up the drug fluconazole in the Index, it will say it’s on page 9. It's actually on page 8.

Exceptions to the Formulary

You can ask Network Health Medicare Advantage Plans to make an exception to our prescription drug restrictions. To do so, you should submit a statement from your physician supporting your request. You can call us to ask for an exception, submit your request by using the link below or fax or mail the form found at the link below.

Submit a Request for a Drug Coverage Determination

Requirements and Limits

Some drugs may have an abbreviation in the Requirements/Limits column. This tells you if your drug has any special requirements for it to be covered. These restrictions are used to help make sure certain drugs are used safely and effectively.

Generic Drugs and Brand Name Drugs

Network Health Medicare Advantage plans cover both brand name and generic drugs. Generic drugs have the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.

What Tiers Mean

When you find your drug, it will be listed with a tier number. This is the cost category your drug belongs to. The tier number a drug is on determines what you pay for the drug, and the higher the tier, the more you pay. Our plans have five drug tiers. Within each tier, you pay less when you use a preferred pharmacy. See Drug Costs for copayment amounts for each of our plans.

Tier 1 Tier 2 Tier 3 Tier 4 Tier 5

Preferred Generic Drugs

Generic Drugs and
Non-Preferred Generic Drugs
Preferred Brand Drugs and
Non-Preferred Generic Drugs
Non-Preferred Brand Drugs and
Non-Preferred Generic Drugs
Specialty Drugs