Making changes to the drug lists
There are thousands of medicines on the market, and new ones are introduced all the time. To ensure you get the highest quality, safest and most cost-effective medicines, we continually update the list of drugs our insurance plans cover.
When new medicine hits the market, our first priority is making sure you can get it in a cost-effective way. That means we need to add it to our drug list. (A drug list is the list of medicines that are covered by your insurance. You may also hear this referred to as a formulary.) Log in or create an account to find out which medicines your plan covers.
Who decides which medicines are added to the list?
We have a committee of physicians and pharmacists who maintain our drug list. Our experts review information on new medicines and compare it to the medicines that are already on the list. The goal? Ensuring our drug list comprises the safest and most effective medicines.
When is medicine reviewed?
Our physicians and pharmacists work with industry experts to decide which new medicines should be added to the drug list. We review medicine when:
- It has been approved by the FDA
- It has appeared in published studies
- It has been recommended by doctors and pharmacists
We delete medicine from our drug list when:
- The FDA takes it off the market
- There are concerns about safety or effectiveness
- A similar medicine that works better or has fewer side effects becomes available
- The medicine isn’t used by many people
- The product becomes available over the counter
What factors are considered when changing the drug list?
We consider several factors when we update the drug list. Those factors include whether the drug:
- Has proven effectiveness
- Will help maximize safety and minimize potential errors
- Will improve overall value by lowering cost or improving effectiveness
- Is essential to health
- Is safer, more effective or more cost-efficient than other drugs on the list
- Will improve patient satisfaction because it works well and is easy to take
- Serves the best interests of our members
What should I do if my medicine isn’t on the formulary?
Almost every prescription (95 percent) written for HealthPartners members is on the drug list. However, there may be times when you need to take a medicine that is not on the list. This could happen if:
- Your doctor prescribes a medicine that isn’t on the drug list
- You already tried a medicine on the drug list and it didn’t work
- You want to continue taking a medicine that you were on before you switched to HealthPartners, but it’s not on the drug list
Don’t worry. It’s easy for your doctor to submit a request for an exception.
If the request is approved, your medicine will be covered, even if it’s not on the drug list. In most situations, requests are reviewed and responded to on the day they are received. Your doctor can use this form or contact member services to request your exception.
To ensure you get the right medicine, our reviewers look at the following information from your doctor:
- Medicines on the drug list that you’ve already tried
- Evidence that the medicine you want to take is effective
- Medical necessity
What if my request for an exception is denied?
Even if your original request is denied, you still have options. You and your doctor can appeal the decision. Your doctor can initiate an appeal by:
- Contacting Member Services
- Calling Pharmacy Services at 952-883-5813
- Sending a fax to 952-853-8700 or 888-883-5434
The new request should include any relevant information that wasn’t included in the original request. A medical director will review the appeal within three business days, or you can request an expedited review.
If your request is approved, we’ll let your doctor know. Then, we’ll put the information in our system, so you’re charged correctly when you fill the prescription. If your request is not approved, we’ll tell you and your doctor, and we’ll give you suggestions for other medicines to try.
- January: Commercial and State Programs
- Formulary Update, April 2018, Commercial and State Programs
- Formulary Update, April 2018 Medicare
- Formulary Update, July 2018, Commercial and State Programs
- Formulary Update, July 2018 Medicare
- Formulary Update, October 2018 Commercial and State Programs
- Formulary Update, October 2018 Medicare