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Mandatory Generic: The Prescription Drug benefit is a “Mandatory Generic” program. Each Prescription will be filled as a Generic when available. If the Physician or the Covered Person requests a Brand Name Medication when there is an FDA “AB” rated Generic available, the Covered Person will be charged the applicable Deductible/Co- insurance/Co-payments plus the difference in the price of the Brand Name Medication and the available Generic. This charge is referred to as a DAW (Dispense as Written). The fee is applicable regardless of prescriber request or member request.

Medication Sourcing Classification Changes: Sourcing classification is dictated solely by the pharmaceutical manufacturer industry. These changes occur when multiple manufactures stop producing a drug leaving only one manufacturer (single source) to produce and sell the drug or new manufacturers enter the market to produce and sell a drug where others are already (multi-source). These changes occur intermittently throughout the year and without notice. The changes often result in a tier change which directly impacts the amount you pay in co-payment or co-insurance. As a result there may be instances where the tier on the formulary may not match the amount you are responsible for. The formulary is constantly updated to account for these types of changes.

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*adhd/anti-narcolepsy/anti-obesity/anorexiants**allergenic extracts/biologicals misc**alternative medicines**amebicides**aminoglycosides**analgesics - anti-inflammatory**analgesics - nonnarcotic**analgesics - opioid**androgens-anabolic**anorectal agents**anorectal and related products**antacids**anthelmintics**antianginal agents**antianxiety agents**antiarrhythmics**antiasthmatic and bronchodilator agents**anticoagulants**anticonvulsants**antidepressants**antidiabetics**antidiarrheal/probiotic agents**antidiarrheals**antidotes and specific antagonists**antidotes**antiemetics**antifungals**antihistamines**antihyperlipidemics**antihypertensives**anti-infective agents - misc.**antimalarials**antimyasthenic agents**antimyasthenic/cholinergic agents**antimycobacterial agents**antineoplastics and adjunctive therapies**antiparkinson agents**antiparkinson and related therapy agents**antipsychotics/antimanic agents**antiseptics & disinfectants**antivirals**assorted classes**beta blockers**biologicals misc**calcium channel blockers**cardiotonics**cardiovascular agents - misc.**cephalosporins**chemicals**contraceptives**corticosteroids**cough/cold/allergy**dermatologicals**diagnostic products**dietary products/dietary management products**digestive aids**diuretics**endocrine and metabolic agents - misc.**estrogens**fluoroquinolones**gastrointestinal agents - misc.**general anesthetics**genitourinary agents - miscellaneous**gout agents**hematological agents - misc.**hematopoietic agents**hemostatics**hypnotics**hypnotics/sedatives/sleep disorder agents**laxatives**local anesthetics-parenteral**macrolides**medical devices and supplies**medical devices**migraine products**minerals & electrolytes**miscellaneous therapeutic classes**mouth/throat/dental agents**multivitamins**musculoskeletal therapy agents**nasal agents - systemic and topical**neuromuscular agents**nutrients**ophthalmic agents**otic agents**oxytocics**passive immunizing agents**passive immunizing and treatment agents**penicillins**pharmaceutical adjuvants**progestins**psychotherapeutic and neurological agents - misc.**respiratory agents - misc.**sulfonamides**tetracyclines**thyroid agents**toxoids**ulcer drugs**ulcer drugs/antispasmodics/anticholinergics**urinary anti-infectives**urinary antispasmodics**vaccines**vaginal and related products**vaginal products**vasopressors**vitamins*
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Formulary Effective Date: 08/01/2022
Updated:
07/2022

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