FAQs

What drugs are not covered?

The following drugs are not covered under the State policy.

What is a Formulary?: A formulary is a list of drugs that a health plan covers. Formulary drugs treat a variety of illnesses. We keep up to date on changes in drugs.
How are drugs selected for the formulary?: Health Plans use a group of doctors and pharmacists (P & T Committee) to make these choices. First, we get input from main doctors. Then, our Plan’s Medical Directors and Pharmacists get input from our other health plans. Then, we choose the best drugs. Often, two drugs are equally safe and effective. There can be differences in their known benefits.

After a review, the committee may add drugs to the list. New drugs may be added every six months. We try to remove drugs once a year. Some drugs are a benefit exclusion under the Medicaid benefit policy.
But, what if my doctor thinks I should have a drug that is not on the formulary?: Your doctor may write for any drug. Your doctor can request a change from the drug list. Your doctor must show that a drug not on the list is necessary to treat you in order for the drug to be covered.

How do I get a Pre Approval?: Some drugs require pre approval by your doctor.
Why do some drugs require Pre Approval?: Some drugs need pre approval because our doctors feel they should only be used after other drugs have been tried first. Call Customer Service to find out which drugs need pre approval.

Why are there quantity limits?: Quantity limits are set on drugs for different reasons. Limits are set because some drugs have a maximum limit or a maximum dose.
How quantity limits are set?: The limits are reviewed and set by clinical staff.
What is the exception process?: Your doctor can contact us so our medical staff can review the medical information provided by your doctor and decide if they will make an exception.

Frequently asked questions