The Formulary
The Formulary represents the cornerstone of drug therapy, quality assurance and cost containment efforts. Memorial Hermann Health Plan and CapitalRx have created the formulary to give members access to quality and affordable medications, as well as to provide physicians with a reference list of preferred medications for cost-effective prescribing.
The Formulary was developed by a 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 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.
The Formulary was developed by a 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 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
Each prescription drug product is placed in a Tier from 1 to 3 that determines your cost-share:
- Generic (Tier 1)
- Preferred Brands (Tier 2)
- Non-Preferred Brands (Tier 3)
Generic drugs are displayed in lowercase italicized lettering. Brand drugs are displayed in UPPERCASE LETTERING. Brand drugs may be removed from your drug list after a generic equivalent becomes available. Generic drugs generally have the lowest cost share.
Drugs that do not appear on this list are excluded under the formulary. If your prescribed medication is not covered, please contact your doctor to see if a covered alternative is right for you. If your prescriber determines that you require a drug that is not covered on the formulary, a drug exception request with clinical documentation may be submitted.
If your plan offers a prescription drug benefit for preventive drugs listed under the Affordable Care Act or a Health Savings Account, the drugs will be flagged below. These drugs may be available at $0 or a lower cost share than regularly tiered drugs depending on your benefit.
Additional restrictions may apply and will be indicated next to the drug on the list below. Some drugs may only be covered for members within a certain age range or gender due to recommendations based on FDA-approved labeling and clinical practice guidelines. Some drugs are subject to prior authorization, step therapy, or quantity limits. Please reference the legend below for more information.
Medications with a Specialty Drug flag are used to treat complex medical conditions (e.g. hepatitis, multiple sclerosis, and hemophilia) and require special handling, administration, and member care management. Depending on your pharmacy benefit design, specialty drugs may be part of a benefit with specific coverage and copay requirements that differ from drugs in Tiers 1 – 3. If you do not have a defined specialty benefit, your copay may be based on whether the drug is generic or BRAND, therefore Tier 1 or Tier 3 copays may apply.
Note that some drug classes may be excluded by your plan or not covered on your pharmacy benefit. If you have questions about your coverage, please call the number on the back of your member ID card.
Special Code/Designation on the Formulary:
You can find out if your drug has any additional requirements or limits by looking in the formulary, next to your drug name for special designations or codes. You can also get more information about the restrictions applied to specific covered drugs by visiting Utilization Management or by calling the number on the back of the ID card.
Additional Formulary Information
Preventative Drug List (ACA)
Under the health reform law (Affordable Care Act), benefit plans must cover certain Preventive Care Medications at 100% - without charging a copay, coinsurance or deductible. This is a list of prescription and OTC drugs with a valid prescription that is required to be covered by ACA regulations at $0 copay at any network pharmacy.
HCR Preventive Care
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. The member bears the financial responsibility for the cost of a brand-name medication, when a generic equivalent is available.
Exclusions
Depending on pharmacy benefit plans, some medications listed may not be covered based on benefit design purchased by the employer group.
Examples of contractual exclusions include, but are not limited to:
- Appetite suppressants
- 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
- Some types of vitamins (non-prenatal)
Please refer to Evidence of Coverage or plan documents for more information on the Exclusions.