Prescription Blue PDP Premium Standard Formulary

Overview

The Prescription Blue Prescription Drug Plan (PDP) Premium Standard Formulary is a curated list of prescription medications that are covered under the Prescription Blue Premium plan. The formulary is designed to balance clinical effectiveness, safety, and costefficiency for the plans members. By grouping drugs into tiers, the plan encourages the use of therapeutically equivalent, lowercost alternatives while still providing access to newer and specialty medicines when clinically appropriate.

All drugs listed on the Standard Formulary have undergone a rigorous review process by Prescription Blues Pharmacy and Therapeutics (P&T) Committee. The committee consists of physicians, pharmacists, and healthplan clinicians who evaluate clinical evidence, FDA approvals, and realworld utilization data. The formulary is updated twice a year, with interim adjustments possible when new safety information emerges.

Coverage Tiers

The Standard Formulary uses a fivetier structure. Each tier is associated with a specific member costshare level, ranging from $0 for the lowestcost generics to higher copays for specialty medications.

Members are encouraged to start therapy with the lowesttier drug that is clinically appropriate. Pharmacists may suggest therapeutic alternatives at a lower tier, which can reduce outofpocket costs without compromising efficacy.

Member Benefits

• Lower outofpocket costs: By using preferred generics (Tier2) members typically pay less than $10 per prescription.
• Access to highcost specialty therapies: Tier5 drugs are covered with a predictable coinsurance rate, and priorauthorization programs help ensure medical necessity.
• Mailorder convenience: 90day supplies for Tier13 drugs are available at the same copay as a 30day supply, reducing pharmacy trips.
• Formulary management tools: An online drug lookup, mobile app, and pharmacist counseling hotline help members understand coverage, find lowercost alternatives, and navigate priorauthorization requirements.
• Clinical safety monitoring: The P&T Committee reviews adverseevent reports and updates the formulary when safety concerns arise.

Exceptions & Appeals Process

While the formulary aims to meet the majority of therapeutic needs, there are cases where a prescribed drug is not covered or is placed on a higher tier than a clinically comparable alternative. Prescription Blue provides two pathways for members and prescribers:

1. Prior Authorization (PA)

A priorauthorization request is required when a Tier5 specialty drug or a nonpreferred brand (Tier4) is prescribed. The prescribing physician must submit clinical documentation demonstrating medical necessity. Most PA requests are processed within 48hours for standard drugs and 57days for specialty medications.

2. Formulary Exception (Appeal)

If a member believes a lowertier alternative is unsuitable, they may request a formulary exception. The appeal must include:

• Letter from the treating physician outlining why the preferred tier drug is ineffective or contraindicated.
• Relevant medical records, lab results, or imaging that support the claim.
• Any prior trial of lowertier agents and the outcomes.

Prescription Blues appeals team reviews the submission and issues a decision within 15business days. Exceptions are granted on a casebycase basis, with the possibility of temporary coverage while further evidence is gathered.

How to Use the Standard Formulary

Members can maximize their benefits by following these steps:

1. Check drug tier before filling: Use the online formulary lookup tool or the mobile app to confirm the tier and associated cost.
2. Ask the pharmacist about generics: If a brandname drug is prescribed, inquire whether a preferred generic exists (Tier2) and whether it is therapeutically equivalent.
3. Enroll in mailorder for chronic meds: For Tier13 chronic medications, the 90day mailorder option can reduce both cost and pharmacy trips.
4. Submit priorauthorization promptly: When a Tier4 or Tier5 drug is needed, start the PA process immediately to avoid treatment delays.
5. Utilize patient assistance programs: For highcost specialty drugs, Prescription Blue partners with manufacturers copayassistance programs that can lower the members outofpocket expenses.