Formulary management procedures

The WellFirst Health list of covered drugs/formulary is reviewed monthly. As newer generic drugs are approved for use, changes and updates are made on a regular basis.

In addition to updating the status of covered drugs, restrictions are also modified as necessary. Here is an update of restrictions and limitations associated with the drug formulary:

  • Closed formulary. WellFirst Health employs a closed formulary. If a drug is not listed on the drug formulary, it’s not covered by the member’s pharmacy benefit. If the member chooses a product not on the formulary, the member is responsible for 100% of the cost of the drug.
  • Mandatory generic substitution. If a drug is available in a generic version, WellFirst Health may require you to use the generic version. If the generic version of the drug is mandated and the patient chooses to receive the branded version, the patient is responsible for the highest-tier branded copay plus the ingredient cost difference between the brand and generic versions. If the patient’s physician requests the branded version, the patient is only responsible for the highest tier branded copay.
  • Prior authorization. When a drug needs prior authorization, that means your physician must receive approval prior to prescribing the drug. The list of prior authorized drugs and the request forms are available
  • Step therapy. Step edits are often used to require generic or preferred drug use before using a non-preferred drug. When a step edit is in place, you must try the preferred drugs before receiving approval for the non-preferred drugs. Step edits are completed point-of-service at the pharmacy, and there are no prior authorization requirements.

Navitus uses a Pharmacy and Therapeutics (P&T) Committee to make all drug therapy decisions, including step therapy. They evaluate the safety and efficacy of a product, including clinical practice guidelines, based on available medical literature.

Priority is put on current U.S. Guidelines, which:
  • Acknowledge any potential conflict of interest
  • Describe the methodology of guideline development
  • Emphasize inclusion of peer-reviewed publications and evidence-based research
  • Incorporate widely-accepted medical practice
When higher-quality guidelines are unavailable, we consider others which:
  • Come from organizations outside the U.S.
  • Focus primarily on expert or consensus-based opinion
  • Lack any of the areas mentioned above
The P&T Committee considers cost only after it makes the clinical determination. Once the medication is evaluated, if a lower cost alternative exists, a step therapy protocol is set up.
Step therapy is a formulary tool used to manage high-cost medications while improving health. When a medication requires step therapy, you are encouraged to try a less costly, clinically equivalent drug first. After trying this therapy, you can work with your prescriber to decide what is best for you.

You and your prescriber may find that the lower cost medication works well. If the medication isn’t working or your need is medically necessary, please ask your prescriber to contact Navitus.
Step therapy is an effective tool for ensuring that you receive safe, effective, high-quality medications at a lower cost.
  • Specialist restrictions. Specialist restrictions limit the prescribing of a drug to a unique specialty. These decisions are based on the indications and specific drug uses.
  • Quantity level limits. Quantity level limits restrict the supply of a prescription that may be dispensed either per prescription or per a specific amount of time.
  • Specialty pharmacy. If a drug is available or mandated to be dispensed by a specialty pharmacy, the specialty pharmacy designation will be applied.