What is a Drug Formulary?

The Drug Formulary is a detailed list of safe, effective and cost-effective medications.

Senior Preferred covers the drugs listed in our Formulary as long as the drug –

  • is medically necessary
  • prescription is filled at a Senior Preferred network pharmacy
  • meets other plan rules

Not all prescription drugs are covered, so make sure to check the formulary when you receive a prescription.

Most drugs fall into the following categories –

  • Non-formulary: Some drugs or groups of drugs are not covered on our formulary. In some cases, this is because we have alternative drugs on our formulary that we cover instead. In other cases, there are Medicare rules which prevent us from covering the drug.
    Examples include:
    • drugs to treat hair loss
    • sexual dysfunction treatments
    • drugs for cosmetic use
    • over-the-counter (OTC) medications
  • Restricted: Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
    • Prior Authorization: This means that you or your doctor will need to get approval from us before you fill a prescription. If you don’t get approval, we may not cover the drug.
    • Quantity Limits: This means that there is a limit on the amount of the drug that we will cover. For example, a drug that has a Quantity Limit of "30 per 30 days" means that the drug is limited to 30 tablets per 30 days (in other words, 1 tablet per day).
    • Step Therapy: This means that you must 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, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you (or you are unable to take it), we will then cover Drug B.
  • Tiers: Drugs on our formulary are assigned to a tier. The tier that a drug is on determines how much you pay for that drug. You will generally pay more for drugs at a higher tier.

Tier 1 Preferred Generic

Tier 1 Preferred Generic: Generic drugs covered at the lowest cost-sharing level

Tier 2 Generic

Tier 2 Generic: Generic drugs

Tier 3 Preferred Brand

Tier 3 Preferred Brand: Brand drugs covered at the lowest cost-sharing level available to Brand drugs

Tier 4 Non-preferred Drug

Tier 4 Non-preferred Drug: Brand and generic drugs covered at the highest cost-sharing level.
Senior Preferred's Pharmacy and Therapeutics (P&T) committee has determined these drugs are less clinically and cost effective

Tier 5 Specialty

Tier 5 Specialty: High cost and some injectable drugs

Some drugs are covered only at certain times. Check your Evidence of Coverage (EOC) for full information.

What if my doctor prescribes a new medication in Tier 4?

A medication may be placed in tier 4 if it is new and not yet proven to be safe or effective, or there is a similar drug on a lower tier of the formulary that may provide you with the same benefit at a lower cost.

For example, lots of people take blood thinners (anticoagulants). The Senior Preferred formulary has blood thinners in several different tiers. If your doctor prescribes you a blood thinner in Tier 4 (Non-preferred Brand), you might want to ask if a blood thinner in a lower tier would work just as well. Your cost will generally be less - sometimes the difference is only a few dollars and sometimes the difference is hundreds of dollars.

What is a Generic (Generic Equivalent)?

A generic equivalent means that two different medicines have the same active ingredient and work the same way A generic equivalent is usually less expensive than the brand name drug.

A generic equivalent:

  • Has the identical amount of the same active ingredient in the same dosage
  • Has the same route of administration (if one is a tablet, the equivalent is also a tablet)
  • Is expected to have the same clinical effects
  • Is expected to be just as safe as another medicine

The United States Federal Food and Drug Administration (FDA) decides which drugs are equivalent to each other.

Are Generic Drugs Safe and Effective?

Yes, according to the Federal Food and Drug Administration (FDA). Generic medications must meet the same standards for purity, strength and quality as brand name drugs. Generic drugs must be approved by the FDA before they can be sold.

Generic drugs may look different from the brand name drug. Sometimes the FDA requires a generic drug to look different than a brand name drug. For example, the tablet color, shape, or size might be different.

You can view how different medications look by logging into MyChart and accessing the Pharmacy Benefit Online Tool.

How do drugs get on the formulary?

The drugs on the Senior Preferred Formulary are selected with help from the Pharmacy and Therapeutics (P&T) Committee. The P&T Committee is made up of doctors and pharmacists who care for Senior Preferred members. The P&T Committee meets every three months to review medications. They decide the formulary tier and restriction status of each medication.

A variety of factors are considered. They include -

  • Safety
  • Side effects
  • Drug interactions
  • How well the drug works
  • Dosing schedule and dose form
  • Appropriate uses
  • Cost-effectiveness

In making formulary decisions, the committee uses the most up-to-date information on the medication from a variety of sources. These include published clinical trials, data submitted to the Food and Drug Administration (FDA) for drug approval and recommendations from local or national treatment guidelines. The committee works with local health care practitioners who are experts in the use of the drug class under review.

That means that the Senior Preferred formulary is made up of medicines that are a necessary part of a quality treatment program.

What is Prior Authorization?

Some medications need approval by the Pharmacy Department before Senior Preferred will cover them. This is called Prior Authorization.

You can also see which drugs need Prior Authorization by looking at the Drug Formular.y. Drugs that need Prior Authorization will have (PA) after the drug name.

How does Senior Preferred decide which drugs need Prior Authorization?

The Senior Preferred Pharmacy and Therapeutic (P&T)s Committee reviews current medical studies and gets input from plan physicians. Together, they decide of a drug should have Prior Authorization.

What is a mail service pharmacy?

A mail service pharmacy delivers medicines to your home by mail. By using a mail service pharmacy you -

  • Can get a 90-day supply of medication
  • May pay a lower copay

If you are interested in using a mail service pharmacy, please call Customer Service.

Senior Preferred members are not required to use a mail service pharmacy.

How do I request reimbursement for a prescription I paid for myself?

When you buy your medicine at the pharmacy, it's best to use your Senior Preferred ID card.

If you don't have your ID card and you need to pay out-of-pocket, you can mail the pharmacy's itemized receipt to us at:

Senior Preferred Pharmacy Department
840 Carolina Street
Sauk City, WI 53583

Note: Senior Preferred uses a Pharmacy Benefit Manager that has contracts with thousands of pharmacies.

That means that when you use your Senior Preferred ID card to buy medicine, the pharmacy may charge less than their usual price.

When you don't use your ID Card, you won't get the lower cost. That also means that when we reimburse you for the medicine, we only pay what we would normally pay the pharmacy. It may not be the full amount you paid the pharmacy for the medicine.

What are my prescription copays or coinsurance?

The amount you pay for your medication(s) is in your Summary of Benefits.

You can go to the Summary of Benefits in the Important Links box on the right,the Copayment Amounts page, or login to MyChart to access the Pharmacy Benefits Online Tool.

What is an over-the-counter medication (OTC)?

OTC medications can be purchased without a prescription.While OTC medications are NOT covered by Medicare Part D or Senior Preferred, you may be able get a discount at the pharmacy If your doctor writes a prescription for an OTC, you can fill it at your pharmacy using your Senior Preferred ID card to get a discount.

Note: the cost of OTC drugs is not applied to your yearly out-of-pocket maximums.

What if I already have prescription drug coverage through Senior Care, Veterans Administration or a Retiree Plan?

Anyone with current drug coverage through Senior Care, Veterans Administration (VA), Tricare, or a Retiree Plan can choose a Medicare Advantage plan without Part D drug coverage.

You can avoid penalties if your existing drug coverage is at least as good or better than Medicare Part D coverage. Please contact Customer Service for further details.

What is my prescription coverage if I am out of the service area?

Senior Preferred Part D drug coverage uses a Pharmacy Benefit Manager (PBM). The Senior Preferred PBM has contracts with more than 60,000 pharmacies nationwide. That means you will have coverage for prescription drugs outside of our service area as long as you choose a pharmacy through the Senior Preferred PBM.

You can find the Senior Preferred PBM:

  1. Login to Senior Preferred MyChart and click on the Pharmacy Benefits Online Tool.
  2. Access the Pharmacy Benefits Online Tool directly.

Learn more about the Pharmacy Benefits Online Tool.

What can I do if my prescription drug requires a Prior Authorization, or is not covered?

If your doctor wants you to have a medicine that needs Prior Authorization, the doctor or clinic can fill out a Medicare Prescription Drug Coverage Determination Form.

This form is used if you -

  • Need a drug that is not on the Senior Preferred Formulary (list of covered drugs)
  • Have been using a drug that was covered in the past but has been removed from the Formulary during the plan year
  • Need a prior authorization for the drug your doctor has prescribed
  • Have evidence that it would be bad for you to try another drug first before getting the drug your doctor prescribed (Step Therapy)
  • Want more tablets than are allowed by the Formulary Quantity Limit
  • Find out your doctor has prescribed an expensive drug, but there's a cheaper drug and you want to pay that lower amount
  • You use a drug that had a lower copay tier in the past, but has been moved to a higher copay tier
  • Found out that the drug plan charged a higher copay than it should have
  • Want to be reimbursed for a covered prescription drug that you paid for out of pocket.

If your Request for a Medicare Prescription Drug Coverage Determination is denied, you can still take the medication, but Senior Preferred may not pay for it.

Read more about the Exception Request process (asking for prior authorization or formulary exceptions).

What if my medicine is not on the formulary?

If a drug is not on the formulary, it is not covered by Senior Preferred. However, you and your doctor may request that a non-formulary drug be covered by filling out a Medicare Prescription Drug Coverage Exception Form. Senior Preferred will then review your request based on your unique situation.

See the Exception Request section for more information about how this process works.

What is Step Therapy?

Some prescription drugs require Step Therapy. Step Therapy means that you have to try one or more drugs first, before Senior Preferred will cover the prescribed drug. You can see which medicines require Step Therapy by looking at the Drug Formulary. These drugs will have "ST" by the name of the drug.

If your doctor prescribes a drug that requires Step Therapy -

Step one: First, you have to try a different drug (a Step 1 drug) to see if that works for you.Talk to your doctor to see if the Step 1 drug would work for you.

Step two: If the Step 1 drug doesn't work, talk to your doctor about what medication you can use instead. The number of drugs you have to try first depends on which drug your doctor originally prescribed .

You can request an exception so you don't have to do Step Therapy if -

You already went through these steps and know the other drugs won't work (and you have medical records that show this)

You can't go through the steps for medical reasons.

If Senior Preferred approves your request to step directly to the prescribed drug, that also means you will pay the copay at the its drug tier level. That tier is usually higher than the medicine at a lower step or tier level.

If your Request for a Medicare Prescription Drug Coverage Determination is denied, you can still take the medication, but Senior Preferred may not pay for it.

Members and / or their doctors can start the coverage determination process. The Exception Request process also uses the Medicare Prescription Drug Coverage Determination Form.

2020 Printed Formulary

Download Printable Formulary

MyChart

View the Online Pharmacy Benefit Tool (this tool shows your estimated cost) in MyChart.

You can also find information on how to fill your prescriptions by reviewing your Evidence of Coverage (EOC). You can view your plan documents as well as the EOC by logging into MyChart.

This webpage was updated on October 1, 2019.