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EnvisionRx Plus Formulary

The EnvisionRx Plus drug plan uses a comprehensive formulary. The comprehensive formulary is a complete listing 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. Brand medications are those approved by the FDA following the manufacturer’s submission of a New Drug Application (NDA) or a Biologic Licensing Agreement (BLA). Generic medications are those that have been approved following the manufacturer’s submission of an Abbreviated New Drug Application (ANDA). In some cases a medication with a "generic name" has actually been approved by the FDA via the NDA application rather than the ANDA application. When this happens the prescription will process for the brand cost-share instead of the generic cost-share.

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 Plan Benefit & Drug Costs tool, or call Member Services at 1-866-250-2005 (TTY/TDD 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.

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.

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 Sumatriptan 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 call EnvisionRx Plus at 1-866-250-2005. TTY/TDD users call 711. Our office hours are 24 hours a day, 7 days a week.

Si tiene mas preguntas sobre su medicamentos cubiertos o necesita los enlaces PDF arriba en un formato diferente o en otro lenguaje, por favor llame a EnvisionRx Plus al 1-866-250-2005. Los usuarios de TTY/TDD debe llamar al 711. Horas de Nuestra Oficina son 24 horas a día, 7 días a la semana.

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Contact Us

For help or more information about the EnvisionRx Plus Medicare-approved Prescription Drug Plan, please call EnvisionRx Plus Member Services at 1-866-250-2005 (TTY/TDD Users should call 711), 24 hours a day, 7 days a week.

Or, write us at:
EnvisionRx Plus
2181 E. Aurora Rd., Suite 201
Twinsburg, OH 44087

Or, fax us at:

Or, send an email to:

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