Group Plan Formularies

​​This page lists important information that your doctor uses when determining the most appropriate course of treatment for you. Formularies include many commonly prescribed medications, both brand name and generic. Check the Formulary List to see if your drug is covered. Prior authorization forms can be used by a prescriber, an enrollee, or the enrollee's representative to request a coverage determination for drugs not listed on the Formulary or for drugs that require a prior authorization in order to be covered.

Pharmacy Forms

Prior Authorization Request Form
Fax completed Prior Authorization forms to Presbyterian Pharmacy Services at (505) 923‑5540 or 1‑800‑724‑6953.
• Synagis Prior Authorization Form
• Synagis Program Information
• Systemic Estrogen Prior Authorization Form for Medicare
• Suboxone/Subutex Prior Authorization Form for Commercial and Medicare Plans
• Weight Loss Medication Prior Authorization Form for Commercial Plans
• Form for OptumRx Mail Order Prescriptions

Commercial Large Group Plan Formularies

Online Commercial Large Group Plans (Non-Metal Plans) Formulary

• Commercial Large Group Plans (Non-Metal Plans) – by Therapeutic Class
• Commercial Large Group Plans (Non-Metal Plans) – Formulary Changes

Commercial Small Group and Individual (Health Insurance Exchange) Metal Level Plan Formularies

Online Individual & Family Metal Plans/Employer Group Metal Plans Formulary

• Individual & Family Metal Plans/Employer Group Metal Plans

Supplement Formulary Information

• A list of drugs that have specific edits/requirements for coverage
• Specialty Pharmaceuticals/Medical Drugs List
• U.S. Food and Drug Administration (FDA) Safety Alerts
• U.S. Food and Drug Administration (FDA) Drug Recalls
• Vancomycin Oral Solution Compounding Pharmacies
• Contraceptives Covered with No Co-Pay

Medicare Advantage Formularies and Formulary Updates

• Presbyterian Senior Care HMO/MediCare PPO

Centennial Care Formularies

Online Centennial Care Formulary

• Centennial Care Formulary – Drugs by Therapeutic Class
• Centennial Care – Formulary Changes
• Drugs Requiring Prior Authorization for Centennial Care Plans

Centennial Care Provider Directories

Online Centennial Care Provider Directory

Medication Therapy Management

• Presbyterian Senior Care HMO/MediCare PPO

Disclaimer

Please be sure a prescription drug benefit is part of your specific coverage before consulting this list. If you do not know which list is correct, please contact the Presbyterian Customer Service Center at 505-923-5678 or 1-800-356-2219 for assistance. TTY users may call 1-877-298-7407.

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 and Presbyterian Insurance Company, Inc. (Presbyterian). 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.