Qualified Health Plans

Formularies and Drug-Specific Pharmacy Coverage Guidelines (PCG)

• 2023 Formulary for AdvanceHealth, Cultivate, EverydayHealth, Individual PPO, and TrueHealth Plans
• 2023 Formulary for Portfolio and PPO HSA Plans
• 2023 Formulary for Standardized Plans

Additional Drug Lists

• Excluded Drugs List
• Tier 1a Prescription Drug List

Forms and Resources

• Mail Order Pharmacy Form
• Pharmacy Prior Authorization Request Form
• Prescription Medication Reimbursement
• QHP Formulary Compound Medication Request Form

PCGs: Drug-Specific (see above in Drug List)

• How to Access Drug-Specific Pharmacy Coverage Guidelines

PCGs: General

• Benzodiazepine Limitation for Quantity and Dosage
• Biologic and Immunological Agents - Oral
• Brand Over Generic Medication Exception
• Compound Medication QHP
• Cost Share Waiver Exception Policy for Preventive Medications
• General Medication Coverage Guideline
• Generic Statin Medications for Prevention Benefit Coverage with Waived Cost Share
• Medication Limitation for Age Gender Quantity and Dosage
• Medications Which Contain Simvastatin 80mg
• Non-Formulary Medications Coverage Guideline for Closed Formularies
• Off-Label Use of Cancer Medications
• Off-Label Use of Non-Cancer Medications
• Opioids Limitation for Quantity and Dosage
• Step Therapy

PCGs: Drugs & devices that may be covered under the Medical Benefit

• Benlysta
• Biologic and Immunological Agents - Injectables
• Biosimilar Step Therapy
• Continuous Glucose Monitoring CGM Device in Interstitial Fluid
• Fensolvi Lupron Depot and Lupron Depot PED
• Hereditary Angioedema Medication Therapy
• Insulin Pumps
• Octreotide Products