Prescription Drugs
Formularies

Learn about generic and brand-name prescription drugs that are covered by Jefferson Health Plans. The lists of drugs, also known as formularies, can be searched by drug name or category or can be downloaded as a PDF.

Contents:

Additional Resources

Drug Recalls

The U.S. Food and Drug Administration keeps an updated list of drug recalls. Any members affected will receive a drug recall letter from Jefferson Health Plans in the mail.

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Prior Authorization and Formulary Exceptions

Sometimes, your doctor would like you to have a drug that is not listed in our formulary. In these instances, the non-formulary medication may be requested through a prior authorization, formulary exception or reimbursement.

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About Step Therapy

Step Therapy is a type of coverage determination that applies to certain drugs. When Step Therapy applies, we require you to try certain drugs to treat your medical condition first before we will cover another drug for that condition.

Here's How it Works:

For example, if Drug A and Drug B both treat your medical condition, Jefferson Health Plans may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Jefferson Health Plans will then cover Drug B.

Drugs subject to Step Therapy are marked with an “ST” code in our print and online formularies.

Contact Us

We are here to help answer your questions about formularies. If you're a member and haven’t found what you’re looking for on this page, please call our friendly Member Relations team at 1-833-422-4690 (TTY 1-877-454-8477).

Frequently Asked Questions

A formulary is a list of covered drugs selected by Jefferson Health Plans in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Jefferson Health Plans will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Jefferson Health Plans network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Yes, our formularycan change. Most changes in drug coverage happen on January 1, but Jefferson Health Plans may add or remove drugs on the formulary during the year, move them to different cost-sharing tiers, or add new restrictions.

The formulary is your way of knowing what drugs are covered under your health plan. There are three ways to search for your drug within the formulary:

  • Alphabetically, by using the first letter of your medication
  • By name, using either the brand name or generic name of your medication
  • By selecting the therapeutic class of the medication you are looking for

A generic drug is approved by the FDA as having the same active ingredient as the brand-name drug. Generally, generic drugs cost less than brand-name drugs. Jefferson Health Plans covers both brand-name drugs and generic drugs.

Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:

  • Prior Authorization: Jefferson Health Plans requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Jefferson Health Plans before you fill your prescriptions. If you don’t get approval, Jefferson Health Plans may not cover the drug.
  • Quantity Limits: For certain drugs, Jefferson Health Plans limits the amount of the drug that Jefferson Health Plans will cover. For example, Jefferson Health Plans provides 60 tablets per prescription for atorvastatin 10 mg. This may be in addition to a standard one-month or three-month supply.
  • Step Therapy: In some cases, Jefferson Health Plans requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Jefferson Health Plans may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Jefferson Health Plans will then cover Drug B.

You can find out if your drug has any additional requirements or limits by looking at the formulary.

You can ask Jefferson Health Plans to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition.

You can ask Jefferson Health Plans to make an exception to our coverage rules. Generally, Jefferson Health Plans will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

If your drug is not included in the formulary, you should first contact Member Relations at 1-833-422-4690 (TTY 1-877-454-8477) and ask if your drug is covered.

If you learn that Jefferson Health Plans does not cover your drug, you have two options:

  • You can ask Member Relations for a list of similar drugs that are covered by Jefferson Health Plans. When you receive the list, show it to your doctor and ask them to prescribe a similar drug that is covered by Jefferson Health Plans.
  • You can ask Jefferson Health Plans to make an exception and cover your drug.