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.
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.
2017 Pharmacy & formulary specifics
| CarePoint | Classic | Prestige | Premier |
|---|---|---|---|
FORMULARY |
FORMULARY |
FORMULARY |
FORMULARY |
| Pre-Authorization Criteria | Pre-Authorization Criteria | Pre-Authorization Criteria | Pre-Authorization Criteria |
| Step Therapy Criteria | Step Therapy Criteria | Step Therapy Criteria | Step Therapy Criteria |
FIND A PHARMACY
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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.
Formulary changes effective 04/01/2017
Finding drugs in the formulary
There are two ways to find your prescription drug within the formulary.
- By category: The drugs are grouped into categories depending on the type of medical condition they treat. For example, if you want to find drugs used to treat a heart condition, you would turn to the category listing and look for “Cardiovascular.”
- By drug name: If you’re not sure what category to look under, try searching for your drug in the index. The index provides an alphabetical list of all the drugs included in our formulary.
If your drug isn’t included
Call our partners in medication services, CVS Caremark (1-855-479-3657, 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.
Related information
- 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.
