Our procedures describe the method for managing the drug formulary to provide the most cost-effective therapy options.
Prior Authorization: We may require you or the member to get prior authorization for certain drugs. This means you’ll need to get approval from SWHP before prescriptions can be filled.
Quantity Limits: For certain drugs, we limit the amount of the drug that SWHP will cover. This may be in addition to a standard one-month or three-month supply.
Step Therapy: In some cases, we require the member to try certain drugs first to treat the medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat the medical condition, SWHP may not cover Drug B unless you try Drug A first. If Drug A does not work, we’ll then cover Drug B.
There may be copayments on prescriptions:
A = A tier generic copay (preferred generic)
B = B tier preferred brand copay
C = C tier non-preferred copay
Drugs not on the formulary may be covered at a non-formulary copay if:
- The drug is medically necessary
- The plan rules are followed
- The drug is not considered an excluded drug
Excluded drugs are not covered by SWHP. For example, a drug used for cosmetic purposes may be considered an excluded drug. Please review an Evidence of Coverage (EOC) document and other plan materials to determine which drugs are excluded from coverage.
Review our drug listings or call Customer Service at 1-800-321-7947 to find out if a drug has additional requirements or limits.