Transcription of Essentials Formulary E1/E4 Effective 12-01-2021
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Essentials Formulary E1/E4 Effective 12-01-2021
Essentials Formulary E1/E4 Effective 12-01-2021 LIST OF COVERED DRUGS How to use this list: On a high-deductible, health savings account (HSA)? Refer to the E1 Formulary . For all covered drugs, once you have satisfied your medical deductible, you will pay your applicable coinsurance until you reach your out-of-pocket maximum for the plan year. The drug tiers do not apply. On a PPO plan? Refer to the E4 Formulary . Your drugs fall into 4 tiers: Preferred Generic (1), Preferred Brand (2), Preferred Specialty (3) and Non-Preferred Drugs (4) Please see the chart on page v for information.
drugs typically used to treat chronic, complex, or rare conditions and may require enhanced clinical support. Specialty Drugs are generally limited to a month supply on dispense. Please check your member booklet for more details. Non-Preferred Drugs (4) Tier 4 includes generic, brand and specialty drugs. Non preferred drugs are
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