Formulary (Pharmacy and Part D)
The formulary is a list of drugs Clover covers for medically necessary purposes. Clover also partners with in-network pharmacies, which may provide medications at a lower cost.
Find out if your drugs are covered
Clover's comprehensive formulary lists all brand name and generic drugs available for your health needs. Our formulary represents the prescription therapies believed to be necessary for a quality treatment program, and was designed by Clover in consultation with a team of healthcare providers.
Clover covers the drugs listed in our formulary as long as the drug is medically necessary and all plan rules are followed.
Find a pharmacy
We partner with in-network pharmacies to provide prescription drugs to Plan members. In most cases, your prescriptions are covered only if they are filled at a network pharmacy or through our mail order pharmacy service. We will fill prescriptions at non-network pharmacies under certain circumstances described in the Evidence of Coverage.
Learn about 2018 formulary specifics
We require that members meet specific pre-authorization criteria for Clover to cover certain drugs. Additionally, Clover will only cover some medications after the member has tried less expensive options. Finally, patients with certain chronic conditions who take eight or more prescription medications are eligible for the Clover Health Medication Therapy Management (MTM) program, which works with members' doctors and pharmacists to help provide the greatest benefit from their medications.
Changes to our formulary
Clover may add or remove drugs from our formulary throughout the year. If we remove a drug from our formulary, add prior authorization for a drug, add quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must alert members taking that drug about those changes. If we're removing a drug from our formulary, we'll either notify affected members 60 days prior to making that change, or notify them when they request a refill of that drug (at which time the member will also receive a 60-day supply of that drug). If the Food and Drug Administration deems a drug on our formulary to be unsafe, or the drug's manufacturer removes the drug from the market, we'll immediately remove the drug from our formulary and provide notice to members taking that drug.
If your drug isn't included
Call our partners in medication services, CVS Caremark (1-888-479-3657, as listed on your Member ID Card), to discuss options. Or ask your doctor if there's an acceptable alternate medication covered under our formulary.
- Prescription Drug Transition Policy
- Part D Coverage Determinations, Exceptions, Grievances, and Appeals
- Quality Assurance Drug Management Program
- Centers for Medicare and Medicaid Services (CMS): Best Available Evidence (BAE) Documentation - For more information about the BAE policy, contact our Customer Experience Team at 855-479-3657