Learn more about which prescription drugs are covered as part of your CGHC plan
In the past 30 years, we’ve seen an amazing increase in the number of drugs and formulations of drugs available to treat illness and disease. There are so many different medications today that no health insurer could cover them all and keep its plans affordable. At Common Ground Healthcare Cooperative, we use medical evidence to determine which medications to cover that are most effective for our members.
A health plan’s list of covered medications is called its “formulary.” Within our list, we define drugs that fall into the following tiers or categories:
- Certain preventive drugs covered at no cost to you
- Generic medications that are much less expensive than other medications
- “Preferred” brand name drug available at a reasonable cost
- Non-preferred brand name drugs available at higher costs
- “Specialty” medications generally the most expensive drugs on the market
If you are in a copay plan, you can see in your Statement of Benefits that we offer a different copay for these different classes of medications. If you are not in a copay plan, you are still likely to pay less for generic or preferred brand name drugs than those in the non-preferred or specialty category. Talk with your doctor about your options to be certain you are taking the least expensive medication that is effective for your condition. It can save you a lot of money!
Remember, Common Ground Healthcare Cooperative members can go to any network pharmacy to receive covered preventive, generic and brand name medications. We do require that you use our pharmacy network if you are in need of very expensive medications that fall into the “specialty” tier. Additional information can be found in our formulary.
If you wish to search for a specific medication within the PDF Formulary, you can press CTRL F to search. If you are seeking a certain type of medications, you can click on the heading in the Table of Contents to view a list of those covered.
Step Therapy Processes and Requirements
OptumRx’s Pharmacy Utilization Management (UM) Program has Prior Authorization (PA) guidelines* which are listed by drug and include the review of drug indications, set guideline types (step therapy, PA, initial or reauthorization) as well as approval criteria,duration, effective dates, and more. They are based on written, pharmaceutical UM decision-making criteria** that are objective and developed from clinical evidence from the following sources:
- Food and Drug Administration (FDA) information
- Peer-reviewed medical/pharmacy literature, including randomized clinical trials, meta-analyses, review articles, comparative effectiveness research, evidence-based medicine reviews, healthcare technology assessments, and pharmacoeconomic and outcomes research
- Treatment guidelines, practice parameters, policy statements, consensus statements created/endorsed by reputable governmental, medical, and/or pharmacy organizations
- Pharmaceutical, device, and/or biotech company information
- Medical and pharmacy tertiary resources, including those recognized by CMS
- Relevant and reputable medical and pharmacy textbooks and or websites
*These are specific to health plans and insurers utilizing our Select and Premium drug lists only. Prescription drug benefits may be covered under plan-specific formulary for which these guidelines may not apply. We recommend you visit your health plan’s website for Prescription drug benefit coverage.
** OptumRx’s Senior Medical Director provides ongoing evaluation and quality assessment of the OptumRx UM Program.
Prior Authorization and Exception Request Procedures for Members
Please contact your provider to submit prior authorization or exception requests. If the prior authorization or exception requests are denied, you may file an appeal using the steps outlined in the Appeals, Grievances and Independent External Review section of your Certificate of Coverage/policy.
Access to this formulary does not guarantee any coverage details or benefits available; it only provides access to view the full list of medications that are available through Common Ground Healthcare Cooperative’s Prescription Drug Formulary. For a complete outline of covered benefits and details on medication coverage, please refer to your policy and the Schedule of Benefits provided in your enrollment packet. Some medications listed on the Prescription Drug Formulary may not be covered under your specific benefit. Where differences are noted, the benefit plan documents will govern. We reserve the right to add or remove prescription drugs from the formulary as deemed necessary. If you have questions regarding your prescription drug coverage, please call Member Services at 877-514-2442.