Presbyterian Health Plan and Presbyterian Insurance Company Formularies

The following Formularies list the covered medications your doctor uses when determining the most appropriate course of treatment for you. The Formulary includes many commonly prescribed medications, both brand name and generic drugs.

You will need Adobe Acrobat to open these files. Please select the Formulary that coincides with your policy:

Commercial Group and Individual Formularies

Updated July 2008

Alphabetical Order

• Commercial Group 2-Tier
• Commercial Group 4-Tier
• Commercial Individual 4-Tier
•    Excluded Behavioral Health Medications for the PIC Individual Plan
• PresMetro/PresSolo 1-Tier Formulary
• PresMetro/PresSolo Generics Listing
• Specialty Pharmaceutical List 

By Therapeutic Class

• Commercial Group 2-Tier
• Commercial Group 4-Tier

2008 Medicare Formularies

• Presbyterian Senior Care Formulary
• Presbyterian MediCare PPO Formulary
• Presbyterian Prescription Drug Plan Formulary

Salud Formulary

• Salud Formulary listed in alphabetical order
• Salud Formulary by therapeutic class

Pharmacy Utilization Controls
Includes formulary and non-formulary drugs:

• These drugs have a 14-day requirement
• These drugs have a 90-day requirement
• Covered diapers
• A list of drugs that require Tablet Splitting
• A list of covered Over-the-Counter (OTC) drugs
• A list of drugs that have specific edits/requirements for coverage
• Suggested alternatives to drugs removed from the Formulary

State NMRx Pharmacy Program

Updated July 2008

• NMR_x Preferred Drug List (alphabetical)
• NMR_x Preferred Drug List (by therapeutic class)
• Medical Exception Process Form (.pdf)
• Addresses and phone numbers of all pharmacies for NMRx patients
• NMR_x PDL for Dual Eligibles (Wrap List) - by Class
• NMR_x PDL for Dual Eligibles (Wrap List) - alphabetical listing
• A list of covered Over-the-Counter (OTC) drugs

Pharmacy Utilization Controls

Includes preferred and non-preferred drugs:

• These drugs have a 14-day requirement
• These drugs have a 90-day requirement
• Covered diapers
• A list of drugs that require Tablet Splitting
• A list of covered Over-the-Counter (OTC) drugs
• A list of drugs that have specific edits/requirements for coverage

Supplement Formulary Information

Form:

• Medical Exception Process Form (.pdf) 

Salud! and NMRx Only:

• Diaper Exception Form (.pdf)
• Nutritional Supp. Exception Form (.pdf)
• Medical Exception Criteria (.pdf)

 

Disclaimer

   Please be sure a prescription drug benefit is part of your specific coverage before consulting this list.
   Coverage for some drugs may be limited to specific dosage forms and/or strengths. Your benefit design determines what is covered for you and what your copayment will be. Please refer to your benefit materials for your specific coverage information.  
   The medications listed on this Formulary/Preferred Drug List (PDL) are subject to change pursuant to the Formulary/PDL management activities of Presbyterian Health Plan. This list is not all-inclusive nor does it imply a guarantee of coverage. In addition, coverage for some drugs listed may be limited to specific dosage forms and/or strengths. Substitution of a generic product for a brand-name drug is mandatory when a generic equivalent is available. If a member requests the brand-name drug in this situation, a pharmacy exception may be required and the member must pay the difference in cost between the generic and branded versions.  Non-formulary medications are not considered for coverage unless trial and failure of Formulary alternatives are documented.

Explanation of Indicators

You will see these indicators next to some drug names:

1. Medical Exceptions - any medication that is on the formulary but requires a medical exception request from the physician. The physician can submit the request via fax, phone or regular mail. If the patient meets established criteria for approval, then the medication will be covered.
2. Step Edit - applies to indicated medications that are available to patients if they meet established criteria. Step edits increase accessibility to medications that would otherwise require a medical exception request. Online coverage of the medication at the pharmacy requires the patient to have a prescription history of established formulary agents or agents determined to indicate a medical necessity for the requested medication. If the patient does not meet these criteria or if the medication is otherwise medically necessary, providers can request the medication by submitting a medical exception form to PHP/PIC. If the request is approved then the medication will be covered.
3. Specialty Edit - applies to indicated medications that are available to physicians with the appropriate specialty. Online coverage of medication at the pharmacy requires the prescription to be written by a physician specialist. The specialist does not have to submit a medical exception request for the medication. An example is Neurologists can prescribe Avonex without requesting medical exception. If it is medically necessary for a patient to be treated with a specialty edit medication, non-specialty providers can request the medication by submitting a medical exception form to PHP/PIC. If the request is approved, then the medication will be covered.

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