Drug Formulary

The Formulary

The Formulary represents the cornerstone of drug therapy, quality assurance and cost containment efforts. Memorial Hermann Health Plan and Navitus Health Solutions has 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 Navitus Formulary was developed by the Navitus 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.

Search for medications online

To search for prescription drugs online, click below. (Please note that by clicking on this link, you will be leaving the Memorial Hermann website).

How To Use The Formulary

The Formulary lists the most commonly prescribed medications alphabetically and by therapeutic class. Drugs listed in UPPER CASE indicate brand name medications and generic drugs are listed with lower case letters. For each drug listed, it is indicated whether that drug falls in a specific tier, any special designation associated with the drug, and what category the drug falls into. These can be defined as follows:

• Tier 1: This tier includes most low-cost, high-value generics and select brands that provide high clinical value. These products are the lowest-net cost for the plan and the lowest copayment for the member.
• Tier 2: This tier includes preferred brands and select generics that are less cost effective.
• Tier 3: This tier includes non-preferred brands and generics that provide the least value because of high cost or low clinical value, or both.
• Tier 4: Specialty Drugs that target and treat complex medical conditions and rare diseases. These medications are often very expensive and require special handling. These drugs are indicated on the formulary with a "MSP" or "SP" symbol.
• Tier 5: Medical Benefit products covered to meet benchmark requirements, indicated on the formulary with a "M" symbol.
• Tier 6: Preventive Drug List as required by the ACA requirements, indicated on the formulary with a "$0" symbol.
• EXC: Drugs or products that are a plan benefit exclusion from coverage.
• NC: Drugs or products that are not covered on the formulary but you can request coverage through a prior authorization request.

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.

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.