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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 and affordable medications, as well as 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 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 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:
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 to inpatient medications or to medications obtained from and/or administered by a physician or a home health agency.
At the end of the Formulary is 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 (877) 633-4461.
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.
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 expenses, as well as 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 based on benefit design purchased by the employer group.
Examples of contractual exclusions include, but are not limited to:
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.