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The Formulary represents the cornerstone of drug therapy quality assurance and cost containment efforts. OptumRx has created the Formulary to give members access to quality, affordable medications and to provide physicians with a reference list of preferred medications for cost-effective prescribing.
The OptumRx Formulary was developed by the OptumRx Pharmacy and Therapeutics Committee (P&T committee). This committee, composed of practicing physicians from various medical specialties, practicing pharmacists, and other health care providers, reviewed the medications in all therapeutic categories based on safety, effectiveness, and cost and selected the most cost-effective agents(s) in each class. Formulary development and maintenance is a dynamic process. The P&T Committee will regularly review new and existing medications to ensure the Formulary remains responsive to the needs of our members and providers.
How To Use The Formulary
The Formulary lists the most commonly prescribed medications by therapeutic class. Medications listed in bold indicate generic medications. Drugs listed in UPPER CASE indicate brand name medications. For each drug listed, it is indicated whether that drug falls in the Generic category, Preferred Brand category or Non-Preferred Brand category. These categories are defined as follows:
- Generics (G): Drugs that contain the same active ingredient(s) as their corresponding brand name drug and have been approved by the Food and Drug Administration (FDA) for therapeutic equivalency to their brand name product - TIER 1.
- Preferred Brands (P): Drugs that have been reviewed by the Pharmacy & Therapeutics Committee and found to have therapeutic advantage or overall value over non-preferred brands, factoring safety, efficacy, and cost - TIER 2.
- Non-Preferred Brands (NP): Drugs that have been reviewed by the Pharmacy & Therapeutics Committee and found not to have significant therapeutic advantage or overall value over alternative preferred brands or their generic equivalents - TIER 3.
- Specialty (SP): Drugs that have that have been reviewed by the Pharmacy & Therapeutics Committee and are created to target and treat complex medical conditions and rare diseases. These medications are often very expensive and require special handling.
To help maximize the pharmacy benefit, preferred formulary alternatives where applicable are provided. Please note the information provided is not intended to substitute the physician's independent medical judgment based on the member's specific needs. The Formulary serves as a reference guide suitable for various prescription drug programs with applicable four-tiered copayment or coinsurance benefit plan designs. As determined by the member's benefit plan, the member may share more of the cost for brand name drugs, especially non-preferred brand drugs. Despite formulary listing, please note that some drugs are excluded by benefit design and therefore are not covered (see Benefit Exclusions/Limitations below). The Formulary applies only to prescription medications dispensed to outpatients by participating pharmacies. The Formulary does not apply inpatient medications or to medication obtained from and/or administered by a physician or a home health agency.
At the end of the Formulary an index listing formulary medications alphabetically with the corresponding chapter number where other medications in that class can be found. While Memorial Hermann Health Plan strives to provide prompt notice of changes and updates, our Formulary, as well as our medication management programs such as prior authorization and quantity level limits, are subject to change. Visit our pharmacy benefit manager website for current information. If you prefer, contact OptumRx Customer Service by calling 1-877-633-4461.
Generic Drug Substitution Policy
Generic drug substitution is permitted if the FDA has determined the generic drug to be equivalent to the brand-name product. Depending on the member's prescription drug benefit plan, one of the following generic substitution policies will be applied. The member's financial responsibility for a brand-name medication when a generic equivalent is available will vary depending on the member's generic substitution program.
Prior Authorization for Medical Necessity
If a brand name drug is medically necessary, the physician can initiate a Prior Authorization for a request for coverage if other formulary alternatives have been tried. Memorial Hermann Health Plan encourages generic substitution, when possible and appropriate, to help reduce the member's out-of-pocket expense, plus help contain the overall cost of the prescription drug benefit.
Over the Counter (OTC) products are not covered. In addition, if a prescription drug is available in the same active ingredient(s), identical strength and dosage form as an OTC product, the prescription product will not be covered. Physicians and pharmacists should guide and refer members to the OTC equivalent product.
Depending on pharmacy benefit plans, some medications listed may not be covered for individual members based on benefit design purchased by the member or employer group.
Examples of contractual exclusions include, but are not limited to:
- Appetite suppressants
- Infertility medications
- Drugs used for cosmetic purposes (wrinkles, hair loss, etc.)
- Injectable drugs (Insulin is covered for all members)
- Allergy serums
- Experimental and Investigational (including off-label use) use
- Some types of vitamins (non-prenatal)
Some member's employer groups may choose to purchase additional coverage for these drug classes, while other employer groups may choose to completely carve out the prescription drug benefit from their Memorial Hermann Health Plan medical benefits.
Prior Authorization Program
Most pharmacy benefit plans include the prior authorization program. Prior authorization helps encourage the appropriate and cost-effective use of certain drugs by allowing coverage only after clinical criteria are met.
Drugs requiring prior authorization are designated in the Formulary by "PA" (Prior Authorization) under the Restrictions information. These drugs require prior authorization before members can obtain them as a covered benefit. Drugs requiring prior authorization are subject to change. Please check your provider manual, contact Memorial Hermann Health Solutions or contact our pharmacy benefit manager for a current list of drugs requiring prior authorization and for their coverage criteria. If prior authorization is required, the physician (or his/her representative) must call OptumRx Customer Service at 1-877-633-4461 or fax the request with supporting clinical information to Memorial Hermann Health Solution's pharmacy benefit manager at 1-866-511-2202.
Download a Prior Authorization Request
Download our Prior Authorization Criteria Detail
Download our Specialty Drug Criteria Detail
Quantity Level Limits
Some drug products may be subject to quantity level limits based on the drug manufacturer's packaging size or adopted clinical guidelines. These drugs are designated in the Formulary by "QL" (Quantity Limits) under the Restrictions information. The purpose of these maximum quantity limits is to ensure the proper billing of products and encourage the use of therapeutically indicated drug regimens. Quantity level limits are subject to change.
Step Therapy Limits
In some cases, Memorial Hermann Health Plan requires 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, Memorial Hermann Health Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, the plan will then cover Drug B.