Health Care 101: What You Need to Know

July 2, 2020

When your doctor prescribes a new medication, how do you know if it is covered? You need to check the formulary, which is the list of medications—both generic and brand name—covered by a prescription drug plan. In most cases, if a medication is not on the formulary, it is not covered by the plan.

Review the points below about how prescription drug coverage under the Health Options Program works, so you know what to expect the next time you fill a prescription.

What you Need to Know Why it is Important
The formulary lists all the covered medications. If a medication is on the formulary, it is covered. Use the Find a Drug Tool, download the Comprehensive Formulary for your Option, or call OptumRx to see if your medication is covered.
The Medicare Rx Options available under the Health Options Program use two different formularies.

The Enhanced and Basic Medicare Rx Options use the Prescription Drug Formulary for the Enhanced and Basic Medicare Rx Options. There are certain medications that are covered only under the Enhanced Medicare Rx Option.

The Value Medicare Rx Option uses the Gold5 Prescription Drug Formulary for the Value Medicare Rx Option.

A doctor’s prescription does not guarantee coverage. If a medication is not on the formulary, it is not covered. If your medication is not on the formulary, ask your doctor if another could work for you.
The formulary can change.

Formularies change to keep up with new therapies, medical practices, Food and Drug Administration (FDA) guidance, and Medicare requirements.

The Comprehensive Formularies for the Medicare Rx Options are updated monthly.

We may contact you if there are changes. If there is a change to the formulary that affects one of your medications, you may receive a letter in the mail from OptumRx or the HOP Administration Unit.
Medications fall into one of five coverage tiers.

The coverage tier identifies how the medication is covered. Generally, the higher the tier, the more it costs.

Sometimes, tiers are specific to one type of drug (e.g., all generic prescriptions are put on Tier 1). Other times, tiers are structured based on drug cost (e.g., lower-cost drugs are put on Tier 1).

It is up to the Plan to decide how to structure their formulary to provide members with cost-efficient options. The Centers for Medicare and Medicaid Services (CMS) reviews formulary decisions and may require changes, to ensure the formulary is created in the best interest of Plan participants.

There may be limits.

The formulary uses the abbreviations to note any limitations or restrictions:

  • Prior Authorization (PA). Approval from the Plan is needed before you fill this prescription. If you don’t get approval, it may not be covered.
  • Quantity Limit (QL). The Plan limits the amount of this drug that will be covered.
  • Step Therapy (ST). You must first try another drug to treat your medical condition before we will cover this one for that condition.
  • Non-Extended Day Supply (NDS). The drug is not available for an extended day supply.

As a reminder, if you are enrolled in a Medicare Advantage plan, the drug formulary, frequency of updates, and any limitations or restrictions will be different. Check with your plan for the most updated formulary.

Get Help

Contact the HOP Administration Unit for assistance with your questions.