Is My Drug Covered?

Our List of Medications, also known as a Formulary, is a list of Part D medications covered by our SelectHealth Advantage plan. You can determine what formulary to look at based on which SelectHealth Advantage plan you are enrolled on.

 

SelectHealth Advantage HMO Formulary

If you are enrolled on the following plans, SelectHealth Advantage HMO is your formulary.

Utah Plans: Wasatch Essential, Wasatch Enhanced, Southwest & Central, or Cache Valley

Idaho Plans: Treasure Valley Essential, Treasure Valley Enhanced, or Magic Valley

Nevada Plans: SelectHealth Advantage Essential Clark County

 

SelectHealth Advantage HMO Formulary

  2018 Lookup Up Tool

  2018 Formulary

  2018 Formulario de Medicamentos Completo

  2019 Lookup Up Tool

  2019 Formulary

 

SelectHealth Advantage Lung Care HMO-SNP Formulary

If you are enrolled on SelectHealth Advantage Lung Care (HMO-SNP) in Clark County, Nevada, this is your formulary.

  2019 Lookup Up Tool

  2019 Lung Care Formulary

 

SelectHealth Advantage Heart & Diabetes Care HMO-SNP Formulary

If you are enrolled on SelectHealth Advantage Heart & Diabetes Care (HMO-SNP) in Clark County, Nevada, this is your formulary. SelectHealth Advantage Heart & Diabetes Care (HMO-SNP) Formulary

  2019 Lookup Up Tool

  2019 Heart and Diabetes Care Formulary

 

How Much Will My Drug Cost?

See how much you will pay for a covered drug. Log in to My Health, click on SelectHealth, 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).

Drugs with Special Requirements

Some drugs have special requirements that must be met before SelectHealth 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).

  Coverage Determination Request Form

 

SelectHealth Advantage HMO

  2018 Prior Authorization Criteria

  2018 Step Therapy Criteria

  2019 Prior Authorization Criteria

  2019 Step Therapy Criteria

 

SelectHealth Advantage Lung Care HMO-SNP

  2019 Prior Authorization Criteria

  2019 Step Therapy Criteria

 

SelectHealth Advantage Diabetes & Heart Care HMO-SNP

  2019 Prior Authorization Criteria

  2019 Step Therapy Criteria

 

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.

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:

 

SelectHealth Advantage HMO

  2018 Negative Formulary Change (Posted 10/01/18)

 

Can I Get a Temporary Supply?

Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to talk with your provider about the change in coverage and figure out what to do.

To be eligible for a temporary supply, you must meet the two requirements below:

The change to your drug coverage must be one of the following types of changes:

  • The drug you have been taking is no longer on our formulary.
  • The drug you have been taking is now restricted in some way

You must also be in one of the situations described below:

  • 2018 Transition Policy
    • You are asking for a temporary supply during the first 90 days you are a member of our plan
      We will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these medications, even if you have been a member of the plan less than 90 days.

    • You are a resident of a long-term care facility
      We will allow you to refill your prescription until we have provided you with a 98-day transition supply, consistent with the dispensing increment (unless you have a prescription written for fewer days). We will cover more than one refill of these medications for the first 90 days you are a member of our plan. If you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that medication (unless you have a prescription for fewer days) while you pursue a formulary exception

      .
    • You are experiencing a change in your level of care 
      If you experience a change in your level of care, such as a move from a hospital to a home setting, we will cover a one-time temporary supply for up to 30-days (or 31-days if you are a long-term care resident) when you use a network pharmacy. During this period, you should use the plan's exception process if you wish to have continued coverage of the medication after the temporary supply is finished.

  • 2019 Transition Policy
    • You are asking for a temporary supply during the first 90 days you are a member of our plan
      We will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refill to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these medications, even if you have been a member of the plan less than 90 days.

    • You are a resident of a long-term care facility
      If you are past the first 90 days of membership in our plan, and a resident of a long-term care facility, we will cover a 31-day emergency supply of that medication while you pursue a formulary exception.

    • You are experiencing a change in your level of care 
      If you experience a change in your level of care, such as a move from a hospital to a home setting, we will cover a one-time temporary supply for up to 30-days (or 31-days if you are a long-term care resident) when you use a network pharmacy. During this period, you should use the plan's exception process if you wish to have continued coverage of the medication after the temporary supply is finished.

  • Pharmacy Networks

    Access your prescription drug benefits conveniently through a network of more than 45,000 pharmacy locations nationwide. Most of our partner pharmacies are national chains, so you are covered while traveling.

     

    100-Day Prescriptions

    Pick up a 100-day supply of your maintenance medications at participating pharmacies or by mail order through Intermountain Home Delivery. This program offers both convenience and cost savings. Register for Intermountain Home Delivery.