Questions? Call us 1-866-393-7668

to Reach a Sales Representative

Contact Us
Drug ID Drug Name Tier Level Value Limits
1053651ABSTRAL 100 MCG TAB SUBLINGUALTier 5: Specialty drugsQL,PA
1053654ABSTRAL 200 MCG TAB SUBLINGUALTier 5: Specialty drugsQL,PA
1053657ABSTRAL 300 MCG TAB SUBLINGUALTier 5: Specialty drugsQL,PA
1053660ABSTRAL 400 MCG TAB SUBLINGUALTier 5: Specialty drugsQL,PA
1053663ABSTRAL 600 MCG TAB SUBLINGUALTier 5: Specialty drugsQL,PA
1053666ABSTRAL 800 MCG TAB SUBLINGUALTier 5: Specialty drugsQL,PA
835726acamprosate calc dr 333 mg tabTier 2: Non-preferred generic drugs
885133ACANYA GEL PUMPTier 4: Non-preferred brand drugs
199150acarbose 100 mg tabletTier 2: Non-preferred generic drugsSTEP,QL
200132acarbose 25 mg tabletTier 2: Non-preferred generic drugsSTEP,QL
199149acarbose 50 mg tabletTier 2: Non-preferred generic drugsSTEP,QL
261313ACCOLATE 10 MG TABLETTier 4: Non-preferred brand drugs
211776ACCOLATE 20 MG TABLETTier 4: Non-preferred brand drugs
207892ACCUPRIL 10 MG TABLETTier 4: Non-preferred brand drugs
207893ACCUPRIL 20 MG TABLETTier 4: Non-preferred brand drugs
207895ACCUPRIL 40 MG TABLETTier 4: Non-preferred brand drugs
207891ACCUPRIL 5 MG TABLETTier 4: Non-preferred brand drugs
809854ACCURETIC 10-12.5 MG TABLETTier 4: Non-preferred brand drugs
809858ACCURETIC 20-12.5 MG TABLETTier 4: Non-preferred brand drugs
882559ACCURETIC 20-25 MG TABLETTier 4: Non-preferred brand drugs

Drugs Alphabetically

Legend

  • LA: Limited Availability. This prescription may be available only at certain pharmacies. For more information, consult your Pharmacy Directory or call customer service at 800-316-3107, 24 hours a day/seven days a week. TTY users should call 800-899-2114.
  • PA: Prior Authorization
  • B/D PA: Prior Authorization: This drug may be covered under Medicare Part B or D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.
  • QL: Quantity Limit
  • STEP: Step Therapy

Brand-name drugs are capitalized (e.g., SINGULAIR) and generic drugs are listed in lower-case italics (e.g., warfarin).

About the Formulary

We may add or remove drugs from our formulary during the year. If we remove drugs, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify members who take the drug of the change at least 60 days before the change becomes effective (or when a member requests a refill). These are recent changes to the formulary. 

Exceptions to the Formulary

You can ask Network Health Medicare Advantage plans to make an exception to our prescription drug restrictions. To do so, you should submit a statement from your physician supporting your request. You can call us to ask for an exception, submit your request by using the link below or fax or mail the form found at the link below.

Submit a Request for a Drug Coverage Determination

What Requirements and Limits Mean

Some drugs may have an abbreviation in the Requirements/Limits column. This tells you if your drug has any special requirements for it to be covered. These restrictions are used to help make sure certain drugs are used safely and effectively.

Generic Drugs and Brand Name Drugs

Network Health Medicare Advantage plans cover both brand name and generic drugs. Generic drugs have the same active-ingredient formula 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.

What Tiers Mean

When you find your drug, it will be listed with a tier number. This is the cost category your drug belongs to. The tier number a drug is on determines what you pay for the drug, and the higher the tier, the more you pay. Our plans have five drug tiers. Within each tier, you pay less when you use a preferred pharmacy. See Drug Costs for copayment amounts for each of our plans.

Tier 1Tier 2Tier 3Tier 4Tier 5

Preferred generic drugs

Non-preferred generic drugs Preferred brand drugs Non-preferred brand drugs Specialty drugs