Is My Drug Covered?
Our List of Medications, also known as a Formulary, is a list of Part D medications covered by your Select Health Medicare plan. You can determine what formulary to look at based on the Select Health Medicare plan on which you are enrolled.
2025 Formularies
Essential Formulary
If you are enrolled on any Select Health Medicare plan except Select Health Medicare Enhanced or Select Health Medicare No Rx, your drugs are covered on the Essential Formulary.
2025 Essential Formulary
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picture_as_pdf 2025 Essential Formulary
picture_as_pdf 2025 Essential Completo Formulario de Medicamentos Cubiertos
picture_as_pdf 2025 Essential Formulary Step Therapy Criteria
picture_as_pdf 2025 Essential Formulary Prior Authorization Criteria
Enhanced Formulary
If you are enrolled on Select Health Medicare Enhanced (HMO) 007, the Enhanced Formulary is your formulary.
2025 Enhanced Formulary
picture_as_pdf 2025 Enhanced Formulary
picture_as_pdf 2025 Enhanced Completo Formulario de Medicamentos Cubiertos
picture_as_pdf 2025 Enhanced Formulary Step Therapy Criteria
picture_as_pdf 2025 Enhanced Formulary Prior Authorization Criteria
How Much Will My Drug Cost?
See how much you will pay for a covered drug. Log in to your Select Health account and then Rx Claims.
You can also see an estimate of how much a drug will cost with the Drug Lookup tool, but keep in mind that your benefits may differ from what is shown.
You can visit our Part D Stages page to understand which stage of coverage you are in and how that will affect your cost.
How Can I Get My Drug Covered?
There may be drugs that aren’t on your formulary or that have special requirements, such as prior authorization or step therapy, that you need to meet before they are covered. If you aren't sure why a drug isn't covered, our Pharmacy team can help. Call 855-442-9900 (TTY: 711).
Drug Exceptions and Prior Authorization
If you need a prescription for a medication that is normally not covered under your plan, you may ask for an exception to your plan’s
prescription drug coverage. Obtaining an exception decision takes between 24 (emergent) and 72 hours (standard). Many requests can
be handled over the phone by calling 855-442-9988 or by filling out the Exception Request Form. Some requests may need to be submitted
by your physician. If the exception is denied, you have the right to appeal that decision as with any other denial.
Drugs with Special Requirements
Some drugs have special requirements that must be met before Select Health will cover them.
Step Therapy drugs require your provider to first prescribe alternative options that are generally more cost effective without compromising
quality. Step therapy may be waived if determined to be medically necessary.
Prior Authorization is required for certain drugs. This process must be completed by your doctor before you fill your prescription.
Quantity Limits are designed to limit the use of selected medications for quality, safety, or utilization reasons. Limits may be on the amount of the medication that we cover per prescription or for a defined period of time.
If your physician believes that you require a medication that is not on your formulary, normally requires step therapy, or exceeds a quantity limit, he or she may request an exception through the prior authorization process or the drug exception process.
Use the links below to see drugs with special requirements on your formulary (the drugs covered by your plan).
Essential Formulary Special Requirements
picture_as_pdf 2025 Step Therapy Criteria
picture_as_pdf 2025 Prior Authorization Criteria
Enhanced Formulary Special Requirements
picture_as_pdf 2025 Step Therapy Criteria
picture_as_pdf 2025 Prior Authorization Criteria
Part B Step Therapy
Some Part B covered drugs require your provider to first prescribe alternative options that are generally more cost effective without compromising quality, including:
Acthar
Adakveo
Anzemet
Apretude
Aralast
Aveed
Avsola
Benlysta
Besremi
Bethkis
Bivigam
Botox
Carimunie
Caspofungin
Cayston
Cimzia
Cinqair
Cinryze
Cuvitru
Dronabinol
Durolane
Durysta
Dysport
Emend (Oral)
Envarsus
Evenity
Eversense
Evkeeza
Fasenra
Feraheme
Freestyle Libre
Gammaked
Gamastan
Gammagard
Gel-One
Gelsyn
Glassia
Haegarda
Hyalgan
Ilaris
Ilumya
Iluvien
Imipenem/
Cilastin
Inflectra
Injectafer
Korsuva
Krystexxa
Lemtrada
Leqvio
Monoferric
Monovisc
Myobloc
Novarel
Nplate
Nucala
Nyvepria
Olinvyk
Orencia
Orthovisc
Ozurdex
Palynziq
Pregnyl
Prialt
Privigen
Qutenza
Remicade
Remodulin
Renflexis
Retisert
Rezurock
Simponi Aria
Sinuva
Soliris
Somatuline
Somavert
Spravato
Supartz
Synribo
Takhzyro
Teriparatide
Testopel
Tezspire
Tobi
Treprostinil
Tysabri
Tyvaso
Ultomiris
Ventavis
Vyepti
Vyvgart
Xeomin
Xgeva
Xolair
Yutiq
Zinplava
Zemaira
Notice of Formulary Updates
Generally, if you are taking a medication on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the medication during the coverage year. If there is new information that the medication is not safe or effective, we will remove it from our formulary.
If we remove medications from our formulary, or add prior authorization, quantity limits, and/or step therapy restrictions on a medication, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the medication, at which time the member will receive a 60-day supply of the medication.
To view any changes, please review the Negative Formulary Change documents:
picture_as_pdf Negative Formulary Change (2-01-2025)