What if my drug is not on the formulary?

What if my drug is not on the formulary?

If a medication is “non-formulary,” it means it is not included on the insurance company’s “formulary” or list of covered medications. A medication may not be on the formulary because an alternative is proven to be just as effective and safe but less costly.

What is a restricted formulary?

A list of medica- tions (formulary) which limits access of a practitioner to some medications. A closed formulary may limit drugs to specific physicians, patient care areas, or disease states via formulary restrictions.

Does TennCare cover prescriptions?

Affordable access to more than 200 generic medications, insulin, diabetic supplies and select mental health drugs. Up to five prescriptions per month (insulin, diabetic supplies, and vaccines do not count against the monthly limit) Discount for many non-covered drugs.

What is the difference between formulary exception and prior authorization?

What Are Prior Authorization and the Formulary Exception Process? The term “prior authorization” may also refer to a commonly used managed care strategy called the “formulary exception process,” which allows exceptions to a plan’s formulary (see A M C P ‘s Concept Series paper, Form u l a ry Management).

What are the different types of TennCare?


  • Medically Eligible.
  • TennCare Medicaid.
  • TennCare Standard.
  • Uninsured.
  • Does TennCare BlueCare cover vision?

    Routine vision and dental services are covered for members under the age of 21. Vision services are covered for members over 21 if they are due to certain illnesses or accidental injuries.

    How are hospital formularies determined?

    The medications and related products listed on a formulary are determined by a pharmacy and therapeutics (P) committee or an equivalent entity. P committees are comprised of primary care and specialty physicians, pharmacists and other professionals in the health care field.

    What is the difference between TennCare and Medicaid?

    TennCare is the state of Tennessee’s Medicaid program. It provides healthcare to mostly low-income pregnant women, parents or caretakers of a minor child, children and individuals who are elderly or have a disability. To get Medicaid, you must meet the income and resource limits. You can apply anytime for TennCare.

    Does TennCare have a copay?

    TennCare Medicaid adults have pharmacy co-pays only. You don’t pay co-pays for other TennCare services. But, TennCare Standard members with incomes at or above 100% of poverty do have co-pays for other kinds of services. Your co-pays may change during the year if there are changes in your family size or income.

    What does non-formulary exception mean?

    The non-formulary exception process provides physicians and members with access to non-formulary drugs and facilitates prescription drug coverage of medically necessary, non-formulary drugs as determined by the prescribing practitioner.

    Why would an insurance company deny a medication?

    An insurance company may deny payment for a prescription, even when it was ordered by a licensed physician. This may be because they believe they do not have enough evidence to support the need for the medication.

    Is TennCare the same as Tennessee Medicaid?

    Does TN Medicaid pay for glasses?

    For adults aged 21 and older, vision services are limited to medical evaluation and management of abnormal conditions and disorders of the eye. The first pair of cataract glasses or contact lens/lenses following cataract surgery are covered.

    How are formularies established?

    The health plan generally creates this list by forming a pharmacy and therapeutics committee consisting of pharmacists and physicians from various medical specialties. This committee evaluates and selects new and existing medications for what is called the (health plan’s) formulary.