Formulary management procedures

Our drug formulary (drug listing) is reviewed each month. Medications are listed by copay tier, with lower tiers associated with lower cost share. We make regular changes to include new generic products and modify restrictions. Here’s an updated list of associated restrictions and limitations:

  • Closed formulary: We employ a closed formulary. If a drug isn't listed, then it's covered by the member’s pharmacy benefit. If a non-formulary drug is clinically necessary, an exception to coverage request may be submitted. The prescribing provider should include a medical reason why formulary options are inappropriate.  
  • Mandatory generic substitution: If a generic drug is available, we may require you to use it. If the generic version of the drug is mandated and you choose to get a brand-name version, you may be responsible for the highest tier branded copay plus the ingredient cost difference between the branded and generic versions. If your physician requests the branded version, you're only responsible for the highest tier branded copay.
  • Prior authorization: When a drug needs prior authorization, your physician must get approval from us before prescribing it to you. Sign in to your member portal to find our prior authorization request form and a list of drugs that require it.
  • Step therapy: Step edits are often used to require generic or preferred drug use before using a non-preferred drug. When a step edit is in place, you need to try the preferred drugs before getting approval for the non-preferred drugs. Step edits are completed point-of-service at the pharmacy and there are no prior authorization requirements.
  • Specialist restrictions: These restrictions limit the prescribing of a drug to a unique specialty. These decisions are based on the indications and uses for the specific drug. 
  • Quantity limits: These limits restrict the supply of drugs that may be dispensed either per prescription or per a specific amount of time. 
  • Specialty pharmacy: If a drug is available or mandated to be dispensed by a specialty pharmacy, the specialty pharmacy label will be applied. 

Step therapy is a formulary (drug listing) tool used to manage high-cost medications while improving health. When a medication requires step therapy, you're encouraged to try a less costly, clinically equivalent drug first. After trying this therapy, you can work with your prescriber to decide what's best for you.

You and your prescriber may find that the lower cost medication works well. If the medication isn’t working, or your need is medically necessary, ask your prescriber to contact Navitus.

Step therapy is an effective tool for ensuring that you receive safe, effective, high-quality medications at a lower cost.

Navitus uses a pharmacy & therapeutics (P&T) committee to make all drug therapy decisions, including step therapy. They evaluate the safety and efficacy of a product, including clinical practice guidelines, based on available medical literature. 

Priority is put on current U.S. guidelines, which:

  • Acknowledge any potential conflict of interest
  • Describe the methodology of guideline development
  • Emphasize inclusion of peer-reviewed publications and evidence-based research
  • Incorporate widely-accepted medical practice

When higher-quality guidelines are unavailable, we consider others that:

  • Come from organizations outside the U.S.
  • Focus primarily on expert or consensus-based opinion 
  • Lack any of the areas mentioned above

The committee considers cost only after it makes the clinical determination. Once the medication is evaluated, if a lower cost alternative exists, a step therapy protocol is set up.