A formulary is a list of covered drugs (both generic and brand name) selected by Nascentia Health Plus in consultation with a team of healthcare providers to offer prescription therapies believed to be an important part of a quality prescription program. Nascentia Health Plus will generally only cover the drugs listed in the formulary, unless your health care provider contacts Nascentia Health Plus and obtains prior approval.
Through our Drug Utilization Review (DUR) program, Nascentia Health Plus reviews the drugs that you are taking to ensure quality care through a disease management approach. We are committed to continuous quality improvement and as part of our review, we assess for issues such as:
- Duplication of drugs
- Drug dosage error or therapy duration
- Inappropriate medication
- Clinical use and misuse
- Over and under-utilization
The Nascentia Health Plus Pharmacy Directory provides a list of Nascentia Heath Plus current network pharmacies.
When taking a medication that is no longer covered by the plan, Nascentia Health Plus wants to ensure your prescription drug transitions are safe and as easy to navigate. Please review the information in the Pharmacy Transition Process (pdf) for guidance on any prescription drug transition.
Is Your Drug Covered By Our Plan?
If a drug you take isn’t covered by our plan and you can’t switch to another drug, you and your prescriber can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If your prescriber says that you have medical reasons that justify asking us for an exception, your prescriber can help you request an exception to the rule. This is called a “coverage determination.”
You and your prescriber can complete the Coverage Determination Request Form (pdf) and submit it to the pharmacy department for consideration.
If we approve your request for a Formulary exception, our approval usually is valid until the end of the plan year. This is true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe and effective for treating your condition.
If we deny your request for a Formulary exception, you can ask for a review of our decision by making an appeal. This is called a “redetermination.”
You and your prescriber can complete the Redetermination Request Form (pdf) and submit it to the Nascentia Health Plus appeals department for consideration.
If your request is denied, you have the right to ask for an independent review of the plan’s decision. You have 60 days from the date of the plan’s Redetermination Notice to ask for an independent review. You can complete the Request for Reconsideration Form (pdf) and submit it to the plan for action.
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
- Prior Authorization: Nascentia Health Plus requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Nascentia Health Plus before you fill your prescriptions. If you don’t get approval, Nascentia Health Plus may not cover the drug.
- Quantity Limits: For certain drugs, Nascentia Health Plus limits the amount of the drug that Nascentia Health Plus will cover. For example, Nascentia Health Plus provides 60 or 90 pills per prescription (depending on the strength of the drug), for oxycodone hcl. This may be in addition to a standard one-month or three-month supply.
- Step Therapy: In some cases, Nascentia Health Plus requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Nascentia Health Plus may not cover Drug B unless you try Drug A first. If Drug A does not work for you, then Nascentia Health Plus will then cover Drug B.
- Generic Drugs: Nascentia Health Plus covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.
Last Updated on April 13, 2021