Formulary FAQs

Select from the following Care Choices Formulary frequently asked questions listed below, or view the latest Care Choices Formulary online.

Q. What is a Formulary?
Q. Who decides which drugs go on the Care Choices Formulary?
Q. How does the Pharmacy and Therapeutics Committee decide which drugs are added to formulary?
Q. What type of formulary does Care Choices have?
Q. Why are certain drugs not covered?
Q. How should I use TV, Radio, Magazine and other media information on prescription drugs?
Q. What should I do if my doctor prescribes a drug that is not covered?
Q. What if the drug my doctor recommends is not on the formulary?
Q. Where do members call if they have questions about which copay applies to a specific medication?
Q. Where can I get a copy of the Care Choices Formulary?

Q. What is a Formulary?
A. A drug formulary is a continually updated list of medications that Care Choices has approved for coverage because of their superior clinical effectiveness, safety and value to our members.

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Q. Who decides which drugs go on the Care Choices Formulary?
A. Each drug is thoroughly reviewed by the Care Choices Pharmacy and Therapeutics Committee. The committee is made up of primary care and specialty physicians from the community, pharmacists and other health care professionals.

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Q. How does the Pharmacy and Therapeutics Committee decide which drugs are added to formulary?
A. The committee reviews each drug using the following information:

• Medical and clinical literature including clinical trials
• Relevant patient utilization and experience
• Current therapeutic guidelines
• Comparison to other available drugs in the same therapeutic class
• Outcomes and economic data
• Provider recommendations
• The safest, most effective drugs that will produce the desired goals of therapy and the most reasonable cost to the health care system (doctor, member, and plan)

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Q. What type of formulary does Care Choices have?
A. Care Choices has a modified open formulary. Care Choices also does not cover certain classes of drugs such as drugs for sexual dysfunction and cosmetic purposes. There are also some medications that require plan approval. Plan approval medications are covered if the patient meets Pharmacy and Therapeutics Committee approved criteria with clinical documentation from the doctor.

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Q. Why are certain drugs not covered?
A. Care Choices Pharmacy and Therapeutics Committee does not cover all new drugs released on the market until the committee reviews them for clinical effectiveness, safety, and value. This process ensures that Care Choices members receive only the highest quality medication that has proven safety and clinical experience. In recent years, there have been several new drugs that were removed from the market due to safety concerns. These concerns were often understood only after the release of the drugs and when many patients were already taking them. After careful and thorough review, the Care Choices Pharmacy and Therapeutics Committee excludes many of these drugs from the Care Choices Formulary.

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Q. How should I use TV, Radio, Magazine and other media information on prescription drugs?
A. As with all medication, you should discuss with your physician before you take them. You should also rely upon your health care provider, who has the most knowledge about your condition, to choose the best medication for your over-all health.

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Q. What should I do if my doctor prescribes a drug that is not covered?
A. If your doctor prescribed a non-covered drug, you can purchase the drug yourself –at full cost or you can discuss with your doctor about available and covered alternatives. If there are no alternatives available, your doctor can submit a letter of medical necessity to Care Choices. While this letter does not guarantee coverage for non-covered medications, your doctor may offer additional information that can be used to increase your chances for obtaining coverage. For information on the Care Choices Appeals and Grievance Process, please refer to your member handbook (that was included in your new Member Information Kit), or call Customer Service.

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Q. What if the drug my doctor recommends is not on the formulary?
A. If the drug your doctor recommends is not on the formulary, your doctor can request coverage by providing clinical information of why other formulary alternatives cannot be used. If the request for coverage is not approved, you can either pay the full cost of the medication or request an alternative from your doctor.

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Q. Where do members call if they have questions about which copay applies to a specific medication?
A. Members should call the Express Scripts Member Help Desk at (877) 293-8963.

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Q. Where can I get a copy of the Care Choices Formulary?
A. Click here to view the most up-to-date formulary. Care Choices also has printed a member formulary brochure that contains the most common treatment classes of medications and which medications are locked out in those classes. You may use this brochure to refer to when a new medication is prescribed for you. To request a copy of the formulary brochure, please call Customer Service. Your doctor also has electronic access to the Care Choices formulary. Care Choices does not print the entire list of covered medications since there are thousands of medications that are covered. If you have specific questions regarding drug coverage, you can call the Express Scripts Member Help Desk at (877) 293-8963 or visit Express-Scripts.com online for access to prescription information.

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