EnvisionRx Plus Formulary
EnvisionRx Plus drug plans use a preferred drug list or formulary. The formulary is a list of drugs covered under your EnvisionRx Plus plan.
The list of covered drugs may change throughout the year. Please refer to our Plan Transition Process.
EnvisionRx Plus covers both brand-name drugs and generic drugs. Generic drugs have the same active-ingredient as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.
The EnvisionRx Plus formulary uses tiers, or levels, to indicate which drugs are available at what price or co-payment. For more information about EnvisionRx Plus tiers and co-payments use the Compare Plans and Costs tool, or call Member Services at 1-866-250-2005 (TTY Users should call 711), 24 hours a day, 7 days a week.
The formulary is reviewed and updated on a regular basis by a team of healthcare professionals. If the formulary changes, affected beneficiaries will be notified.
Prior Authorization
Some medications may require a prior authorization before they can be filled. These drugs are indicated on the formulary with the symbol "PA" after the drug name. Please click on one of the links below for Prior Authorization information for the Silver and Gold Plan.
Step Therapy
EnvisionRx Plus may require you to try certain drugs to treat your condition before we will cover another drug to treat your condition. For example, if Drug A and Drug B both treat your medical condition, EnvisionRx Plus may not cover drug B unless you try Drug A first. If Drug A does not work for you, EnvisionRx Plus will then cover Drug B. these drugs are indicated on the formulary with the letters ST in the Notes column. Please click on one of the links below for Step Therapy information for the Silver and Gold Plan.
Quantity Limits
EnvisionRx Plus limits the amount of the drug that EnvisionRx Plus will cover. For example,
EnvisionRx Plus provides 9 tablets per prescription for a 30-day supply of Sumatriptin 100MG. This may be in addition to a standard one month or three month supply.
Coverage Determination, Grievance & Appeals
If you require a medication that is not on the EnvisionRx Plus formulary and you cannot use a formulary alternative, or if you require an exception to one of our utilization management rules or tiered cost sharing, you have the right to request a coverage determination. Or if you have been denied a coverage determination, you can request a redetermination also called an appeal. The forms below can be used for either request. Refer to our Grievances, Coverage Determinations, & Appeals policy for more details.
Or visit the CMS Medicare website at http://www.cms.hhs.gov/MedPrescriptDrugApplGriev/13_Forms.asp.
Please note by clicking on this link, you will be leaving the EnvisionRx Plus website.
If you have further questions about your covered medications or need the PDF links above in another format or language, please contact EnvisionRx Plus at 1-866-250-2005. TTY users should call 711. Our office hours are 24 hours a day, 7 days a week.
Si usted tiene preguntas acerca de sus medicamentos cubiertos o la necesidad de vínculos más arriba en pdf otro formato o idioma, por favor póngase en contacto con EnvisionRx Plus en 1-866-250-2005. Los usuarios de TTY 711 shoulld convocatoria. Nuestras oficinas están abiertas 24 horas al día, 7 días a la semana.
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