Scott & White Health Plan

Formularies

Preferred Drug List
Group Benefits Program - Plan Year 2012

The drug formularies listed below are updated each month.

• Formulary Sorted by Therapeutic Category (pdf, 100kb)
• Formulary Sorted Alphabetically (pdf, 87kb)

Your health plan includes a three-tier prescription drug benefit, which is administered by Scott & White Health Plan and our Pharmacy Benefit Manager (PBM) in accordance with the plan design specified by the Employees Retirement System of Texas (ERS).

• A 30-day supply of non-maintenance Tier 1 drugs are covered at a $15 retail copayment; Tier 2 drugs are covered at a $35 retail copayment; and Tier 3 drugs are covered at a $60 retail copayment.
• For a 30-day supply of maintenance drugs, Tier 1 drugs are $20; Tier 2 drugs are $45; and Tier 3 drugs are $75.
• Mail order copayments for up to a 90-day supply, including oral contraceptives, are $45 for Tier 1 drugs; $105 for Tier 2 drugs; and $180 for Tier 3 drugs.

Please note that there is a $50 per enrollee plan year deductible. If a brand-name medication is dispensed when a generic is available, you will be responsible for the generic copayment plus the cost difference between the generic and the brand-name medication.

Your specific prescription benefit plan design may not cover certain categories of drugs, regardless of their appearance in this document. Check your Evidence of Coverage (pdf, 1.4mb) or contact Scott & White Health Plan's Member Services Department for those conditions and medications not covered by your plan.  The preferred list of covered drugs is subject to change. When new drugs become available during the year or the Pharmacy and Therapeutics Committee meets, drugs may move from one copayment tier to another.

This document lists some preferred and non-preferred drugs in alphabetical order; it does not contain a complete list of all preferred and non-preferred drugs. If you don't find your medication listed in this guide, you should contact Scott & White Health Plan's Member Services Department. Do not contact ERS for assistance with your medications.

PA Indicates Prior Authorization    
QL Indicates quantity limit
ST Indicates step therapy
* Indicates maintenance medication

Lowercase Names = Tier 1
Uppercase Names = Tier 2

* Maintenance drugs are coded as such if they meet the following criteria:

• Medications that do not require frequent monitoring and dosage adjustments for side effects or therapeutic responses. Certain drugs that may have potential life threatening toxicity when taken as an intentional overdose may be excluded.
• Medications that are used to treat a chronic condition with no therapy endpoint. These drugs are taken continuously but do not provide a cure for the condition being treated.
• Medications that are typically used as outpatient-type drugs.

Note: The Formulary Lists are in Adobe® Acrobat (PDF) format. You may download the current Adobe® Acrobat Reader here.

Copayment and Deductible Information