Presbyterian Health Plan and Presbyterian Insurance Company Formularies

The following Formularies list the covered medications your doctor uses when determining the most appropriate course of treatment for you. The Formulary includes many commonly prescribed medications, both brand name and generic drugs.

You will need Adobe Acrobat to open these files. Please select the Formulary that coincides with your policy:

COMMERCIAL GROUP AND INDIVIDUAL FORMULARIES
Updated July 2008

• Alphabetical Order
  • Commercial Group 2-Tier
  • Commercial Group 4-Tier
  • Commercial Individual 4-Tier
    • Excluded Behavioral Health Medications for the PIC Individual Plan
  • PresMetro/PresSolo Formulary
  • • Tier 0 Listing
    • Tier 1 Listing
  • PresMetro/PresSolo Generics Listing
  • Specialty Pharmaceutical List
• By Therapeutic Class
• • Commercial Group 2-Tier
  • Commercial Group 4-Tier
  • PresMetro/PresSolo Formulary
  • • Tier 0 Listing
    • Tier 1 Listing

MEDICARE FORMULARIES
Updated October 2008

• 2008 Medicare Formularies
  • Presbyterian Senior Care Formulary
  • Presbyterian MediCare PPO Formulary
  • Presbyterian Prescription Drug Plan Formulary
• 2009 Medicare Formularies
  • Presbyterian Senior Care Formulary
  • Presbyterian MediCare PPO Formulary
  • Prior Authorization Criteria for 2009 Formulary
    

SALUD FORMULARY
Updated July 2008

• Salud Formulary listed in alphabetical order
• Salud Formulary by therapeutic class

STATE NMRx PHARMACY PROGRAM
Updated July 2008

• NMRx Preferred Drug List (alphabetical)
• NMRx Preferred Drug List (by therapeutic class)
• Medical Exception Process Form (.pdf)
• Addresses and phone numbers of all pharmacies for NMRx patients
• NMRx PDL for Dual Eligibles (Wrap List) - by Class
• NMRx PDL for Dual Eligibles (Wrap List) - alphabetical listing
• A list of covered Over-the-Counter (OTC) drugs

SUPPLEMENT FORMULARY INFORMATION

Form:

• Pharmacy Authorization Form (.pdf)

Salud! and NMRx Only:

• Diaper Exception Form (.pdf)
• Nutritional Supp. Exception Form (.pdf)
• Medical Exception Criteria (.pdf)

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 Member Services at (505) 923-5678 or 1-800-356-2219 for assistance.

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.

EXPLANATION OF TERMS IN YOUR FORMULARY

You will see these words next to some drug names:

1. Pharmacy Authorization (PA) - a drug that requires prior approval before the Plan will cover it, and when the patient meets the established criteria. The doctor must submit a Pharmacy Authorization Form. The doctor can submit the request by fax, phone, or regular mail.
2. Step Edit (ST) - a drug that requires a prescription history of specific drugs in the pharmacy claims or data system, and these specific drugs must be taken during a given time frame. After the specific drugs have been taken within the given time frame, online coverage of the newly-prescribed drug occurs at the pharmacy. Step Edits make it easier to access drugs that would normally require a Pharmacy Authorization.
3. Specialty Edit (SP) - a drug that requires the first prescription to be written by a specialist. The specialist does not have to submit a Pharmacy Authorization. Online coverage of the drug occurs at the pharmacy.
4. Medical Exception - a drug that is not on the Plan's formulary. Non-formulary drugs require an Exception to the formulary due to the patient's allergy, Patient has adverse reactions to all formulary drugs.
5. • Patient has had no response to all formulary drugs.

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