Formulary Lookup Tool

The following drug categories are excluded from coverage. Prior Authorizations, appeals and clinical reviews are not necessary as these medications are not covered by the plan.

Abortifacient, Blood and Blood Plasma, Cosmetic Drugs, Erectile Dysfunction, Fertility, Miscellaneous Medical Supplies, Nutrients & Dietary Supplements, Weight Loss Drugs, Acne Medications, Compounded Drugs, Growth Hormones, Multivitamins, Nasal Steroids, OTC Products, Proton Pump Inhibitors, and Smoking Deterrents.

All plans have a maximum dollar limit on prescription medication. Any medication with a cost exceeding $1,500 requires a Clinical Review for Authorization.

Disclaimer

Verification of eligibility and/or benefit information is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member's eligibility, any claims received during the interim period and the terms of the member's certificate of coverage applicable on the date services were rendered.
This formulary look-up tool is provided for convenience purposes and is not a guarantee of benefits or coverage.

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