Is My Drug Covered?

Our List of Medications, also known as a Formulary, is a list of Part D medications covered by your Select Health Medicare plan. You can determine what formulary to look at based on the Select Health Medicare plan on which you are enrolled.

2024 Formularies

Essential Formulary

If you are enrolled on the following plans, the  Essential Formulary is your formulary.

Colorado Plans:

Select Health Medicare Essential (HMO) 027
Select Health Medicare Dual (HMO-DSNP) 028
Select Health Medicare Essential (HMO) 029
Select Health Medicare + Kroger (HMO) 030
Select Health Medicare Flex (HMO) 031
Select Health Medicare Choice (PPO) 032

Idaho Plans:

Select Health Medicare Essential (HMO) 003
Select Health Medicare Classic (HMO) 004
Select Health Medicare Classic (HMO) 013
Select Health Medicare + Kroger (HMO) 023
Select Health Medicare Flex (HMO) 024
Select Health Medicare Essential (HMO) 025
Select Health Medicare Choice (PPO) 026

Nevada Plans:

Select Health Medicare Essential (HMO) 012
Select Health Medicare Choice (PPO) 019
Select Health Medicare + Kroger (HMO) 021

Utah Plans:

Select Health Medicare Essential (HMO) 001
Select Health Medicare Classic (HMO) 002
Select Health Medicare Dual (HMO-DSNP) 015
Select Health Medicare Essential (HMO) 017
Select Health Medicare Choice (PPO) 018
Select Health Medicare + Kroger (HMO) 022

2024 Essential Formulary

IdahoColoradoColorado HMO-DSNP

NevadaUtahUtah HMO-DSNP

picture_as_pdf  2024 Essential Formulary

picture_as_pdf  2024 Essential Completo Formulario de Medicamentos Cubiertos

 

Enhanced Formulary

If you are enrolled on the following plans, the Enhanced Formulary is your formulary.

Idaho Plans:

Select Health Medicare Enhanced (HMO) 008

Utah Plans:

Select Health Medicare Enhanced (HMO) 007

2024 Enhanced Formulary

IdahoUtah

picture_as_pdf  2024 Enhanced Formulary

picture_as_pdf  2024 Enhanced Completo Formulario de Medicamentos Cubiertos

 

How Much Will My Drug Cost?

See how much you will pay for a covered drug. Log in to your Select Health account and then Rx Claims.

You can also see an estimate of how much a drug will cost with the Drug Lookup tool, but keep in mind that your benefits may differ from what is shown.

You can visit our Part D Stages page to understand which stage of coverage you are in and how that will affect your cost.

 

How Can I Get My Drug Covered?

There may be drugs that aren’t on your formulary or that have special requirements, such as prior authorization or step therapy, that you need to meet before they are covered. If you aren't sure why a drug isn't covered, our Pharmacy team can help. Call 855-442-9900 (TTY: 711).

Drug Exceptions and Prior Authorization

If you need a prescription for a medication that is normally not covered under your plan, you may ask for an exception to your plan’s prescription drug coverage. Obtaining an exception decision takes between 24 (emergent) and 72 hours (standard). Many requests can be handled over the phone by calling 855-442-9988 or by filling out the Exception Request Form. Some requests may need to be submitted by your physician. If the exception is denied, you have the right to appeal that decision as with any other denial.

Drugs with Special Requirements

Some drugs have special requirements that must be met before Select Health will cover them.

Step Therapy drugs require your provider to first prescribe alternative options that are generally more cost effective without compromising quality. Step therapy may be waived if determined to be medically necessary.

Prior Authorization is required for certain drugs. This process must be completed by your doctor before you fill your prescription.

Quantity Limits are designed to limit the use of selected medications for quality, safety, or utilization reasons. Limits may be on the amount of the medication that we cover per prescription or for a defined period of time.

If your physician believes that you require a medication that is not on your formulary, normally requires step therapy, or exceeds a quantity limit, he or she may request an exception through the prior authorization process or the drug exception process.

Use the links below to see drugs with special requirements on your formulary (the drugs covered by your plan).

 

SPECIAL REQUIREMENTS

 

2024 Special Requirements

Essential Formulary Special Requirements 

picture_as_pdf 2024 Prior Authorization Criteria

picture_as_pdf 2024 Step Therapy Criteria

 

Enhanced Formulary Special Requirements 

picture_as_pdf 2024 Prior Authorization Criteria

picture_as_pdf 2024 Step Therapy Criteria

 

Part B Step Therapy

Some Part B covered drugs require your provider to first prescribe alternative options that are generally more cost effective without compromising quality, including:

Actemra IV
Acthar
Adakveo
Anzemet
Apretude
Aralast
Aveed
Avsola
Benlysta
Besremi
Bethkis
Bivigam
Botox
Carimunie
Caspofungin
Cayston
Cimzia
Cinqair
Cinryze
Cuvitru
Dexcom
Dronabinol
Durolane
Durysta
Dysport
Emend (Oral)
Envarsus
Evenity
Eversense
Evkeeza
Fasenra
Feraheme
Freestyle Libre
Gammaked
Gamastan
Gammagard
Gel-One
Gelsyn
Glassia
Haegarda
Hizentra
Hyalgan
Ilaris
Ilumya
Iluvien
Imipenem/
Cilastin
Inflectra
Injectafer
Korsuva
Krystexxa
Lemtrada
Leqvio
Monoferric
Monovisc
Myobloc
Novarel
Nplate
Nucala
Nyvepria
Octagam
Olinvyk
Orencia
Orthovisc
Ozurdex
Palynziq
Pregnyl
Prialt
Privigen
Qutenza
Remicade
Remodulin
Renflexis
Retisert
Rezurock
Simponi Aria
Sinuva
Soliris
Somatuline
Somavert
Spravato
Stelara
Supartz
Synribo
Takhzyro
Teriparatide
Testopel
Tezspire
Tobi
Treprostinil
Tysabri
Tyvaso
Ultomiris
Ventavis
Vyepti
Vyvgart
Xeomin
Xgeva
Xolair
Yutiq
Zinplava
Zemaira

 

Notice of Formulary Updates

Generally, if you are taking a medication on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the medication during the coverage year. If there is new information that the medication is not safe or effective, we will remove it from our formulary.

If we remove medications from our formulary, or add prior authorization, quantity limits, and/or step therapy restrictions on a medication, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the medication, at which time the member will receive a 60-day supply of the medication.

To view any changes, please review the Negative Formulary Change documents:

picture_as_pdf  Negative Formulary Change (02-01-2024)

Can I Get a Temporary Supply?

Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to talk with your provider about the change in coverage and figure out what to do.

To be eligible for a temporary supply, you must meet the two requirements below:

The change to your drug coverage must be one of the following types of changes:

  • The drug you have been taking is no longer on our formulary.
  • The drug you have been taking is now restricted in some way

You must also be in one of the situations described below: 

  • You are asking for a temporary supply during the first 90 days you are a member of our plan
    We will cover a temporary 30-day supply. If your prescription is written for fewer days, we’ll allow refill to provide up to a maximum 30-day supply of medication. After your first 30-day supply, we will not pay for these medications, even if you have been a member of the plan less than 90 days.

  • You are a resident of a long-term care facility
    If you are past the first 90 days of membership in our plan, and a resident of a long-term care facility, we will cover a 31-day emergency supply of that medication while you pursue a formulary exception.

  • You are experiencing a change in your level of care 
    If you experience a change in your level of care, such as a move from a hospital to a home setting, we will cover a one-time, temporary supply for up to 30 days (or 31 days if you are a long-term care resident) when you use a network pharmacy. During this period, you should use the plan's exception process if you wish to have continued coverage of the medication after the temporary supply is finished.

Pharmacy Networks

Access your prescription drug benefits conveniently through a network of more than 55,000 pharmacy locations nationwide. Most of our partner pharmacies are national chains, so you are covered while traveling.

100-Day Prescriptions

Pick up a 100-day supply of your maintenance medications at participating pharmacies or by mail order through Intermountain Home Delivery. This program offers both convenience and cost savings. Sign up for Intermountain Home Delivery.