What is the HealthPartners Formulary?
A Formulary is a list of drugs selected by HealthPartners, in consultation with a team of health care providers, representing the prescription therapies believed to be a necessary part of a quality treatment program. HealthPartners will generally cover the drugs listed in our Formulary as long as the drug is medically necessary, the prescription is filled at a HealthPartners network pharmacy and the other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.
What are the different tiers within the Formulary?
Effective January 1, 2011, the HealthPartners Formulary has four cost-sharing tiers. They are: Generic, Preferred Brand Drugs, Non-Preferred Brand Drugs and Specialty Drugs. Please refer to your plan's Summary of Benefits to determine your cost within each cost-sharing tier.
- Generic drugs have the same active ingredient Formulary as brand name drugs; however, they generally cost less. Generic drugs are just as safe and effective as brand drugs and are approved by the Food and Drug Administration (FDA).
- Preferred Brand drugs are brand drugs that generally do not have a generic alternative.
- Non-Preferred Brand drugs are brand drugs that generally have one or more generic alternatives.
- Specialty drugs are generally medications used to treat long-term, life-threatening or rare conditions.
Can the Formulary change?
Yes, HealthPartners may add or remove drugs from our Formulary during the year. The Formulary information on this website will be updated monthly.
If we remove drugs from our Formulary; add prior authorization, quantity limits and/or step therapy restrictions on a drug; or move a drug to a higher cost-sharing tier, we must notify our members who take the drug of the change at least 60 days before the date that the change becomes effective. If a member requests a refill of a discontinued drug, the member can receive a 60-day supply of the drug. If the Food and Drug Administration (FDA) deems a drug on our Formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we’ll immediately remove the drug from our Formulary and provide notice to members who take that drug.
If we no longer cover your drug, please talk with your doctor about appropriate alternative therapies available on our Formulary. If there are none, you or your doctor can request a Formulary or tiering exception. If requested during the Annual Enrollment Period and approved, we will start covering your drug on January 1st of the following year. If you’re making the change after January 1st, you can get a temporary supply of the drug while you talk to your doctor.
How do I use the online Formulary?
You input the name of the drug you’re searching. When your results come up, the farthest left column of the chart will list the drug name(s). Brand name drugs are capitalized and generic drugs are listed in lower-case italics. The information in the Requirements/Limits column on the right tells you if HealthPartners has any special requirements to cover the drug. You can click on the items in that column to get more explanation of what each special requirement means.
How much will I pay for HealthPartners-covered drugs?
This depends on the HealthPartners plan you’ve selected. Please consult your Evidence of Coverage for details. If your plan has a deductible, you will pay the full cost until you meet your annual deductible. After that, HealthPartners will pay part of the costs and you’ll pay part of the costs. The amount you’ll pay is detailed in your Evidence of Coverage. In addition, if you qualify for extra help from Medicare for your drug costs, your costs may be reduced from those listed in your Evidence of Coverage.
The amount you pay also depends on whether you fill your prescription(s) at a network pharmacy, out-of-network pharmacy or mail order pharmacy.
Are there any restrictions on drug coverage?
Some drugs that are covered by HealthPartners may have additional requirements or limits on use. These may include:
- Prior Authorization: HealthPartners may require you to get prior authorization for certain drugs. You may need to get this authorization for drugs on the Formulary and/or for drugs that aren’t on the Formulary and were approved for coverage through our exception process. This means you’ll need to get approval from HealthPartners before you fill your prescription. If you don’t, HealthPartners may not cover the drug.
- Quantity Limits: HealthPartners may limit the amount of certain drugs that we cover. For example, we provide 20 units per prescription of Ergomar. This limit may be in addition to a standard 30- or 90-day supply.
- Step Therapy: In some cases, HealthPartners may require you to try another drug first to treat your medical condition before we’ll cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, HealthPartners may not cover Drug B until you try Drug A first. If Drug A doesn’t work for you, HealthPartners would then cover Drug B.
You can determine if any of your drugs have additional requirements or limits by looking at our Formulary.
What if my drug isn’t on the Formulary?
If you cannot find your drug listed in the HealthPartners Printed Formulary, you should first contact Member Services to confirm it is not covered. Member Services and the online Formulary search have the most up-to-date information. If you confirm that HealthPartners does not cover the drug, you have two options:
- Request a printed Formulary from Member Services. Then, bring it to your doctor and ask him or her to prescribe a similar drug that HealthPartners covers.
- Ask HealthPartners to make an exception to cover your drug. See below.
- To ask us to cover your drug under a different cost-sharing tier.
How do I request an exception to the Formulary?
You can ask HealthPartners to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make: To cover your drug even if it isn’t on our Formulary. To waive our coverage restrictions or limits on your drug. For example, HealthPartners limits the amount of certain drugs we’ll cover. If your drug has a quantity limit, you can ask us to waive that and cover more. You or your doctor can request an exception. You can do so by filling out the Coverage Determination Form here.
Where can I get more information?
For detailed information about your HealthPartners prescription drug coverage, please see your Evidence of Coverage, other plan materials or call Member Services.