Small Group Commercial 2020 Formulary
Note: This plan has limits on Opioid Medications. See page footer for details.
NOTE: For members who renewed prior to 1/1/2020 coverage year please see chart below to determine the tiers and cost shares. Please reference your member materials for cost share details.
2019 Benefit Tier Copay/Cost share
2020 Tier Equivalent
Tier 1- Preventive
Tier 2- Generic
Tier 3- Preferred
Tier 4- Non-Preferred
Tier 5- High-Cost Specialty
Opioid anti-tussive limits:
Liquids: Maximum of 240ML per fill.
Tablets/Capsules: Maximum 7-day supply per fill.
Short-acting Opioid (SAO) Limits:
New to therapy: Maximum of 49 MED and Maximum 7-day supply per fill.
Experience with therapy: Maximum of 90 MED.
Long-acting Opioid (LOA) Limits: PA required and Maximum of 90 MED.