New Member Pharmacy Transition Information
PersonalCare uses a three-tier formulary. Tier One drugs include most generics. Drugs
listed in Tier One will cost you the least amount of money. Tier Two drugs include
brand name drugs that are considered formulary or preferred medications. These drugs typically are not available in generic form and will cost you more than the
generics. Most other prescription drugs fall into Tier Three. Tier Three drugs are brand
name or generic medications that are not included in the formulary and are therefore considered non-preferred. Tier Three medications will cost you the most.
It’s important to note that PersonalCare’s formulary likely differs from the formulary
used by your current health plan. Some drugs may be classified differently. For example, PersonalCare may classify a certain drug as Tier Three, while your current
health plan might consider the same drug a Tier Two medication. If you are currently
taking prescription drugs, you may want to consider speaking with your health
care provider to ensure that your current prescriptions qualify as Tier One or Two drugs with PersonalCare. If you are currently taking a drug that is considered Tier
Three by PersonalCare, your provider may be able to assist you in finding a Tier One or Two alternative in order to keep your out-of-pocket costs as low as possible. Some examples of commonly prescribed medications which are on Tier Three for PersonalCare include:
Some prescription drugs require prior authorization from PersonalCare in order to be covered under your pharmacy benefit.
Prior authorization means that approval must be obtained from PersonalCare prior to receiving certain medications. Prior
authorization medications include those that: (1) are not suggested for first-line therapy; (2) may require special tests
before starting them; or (3) have very limited approval for use. If you currently take any of the following prior authorization
medications, please contact your prescribing provider immediately to begin the authorization process:
Step Therapy Program
Some drugs on PersonalCare’s prior authorization list are part of PersonalCare’s Step Therapy program, which operates
under our prior authorization process. Step therapy drugs require the use of one or more first-line
drugs before a second-
drug is approved. First-line drugs
are drugs that are nationally accepted and have been proven to be safe and effective
in treating a condition. Second-line drugs
are designated as such because they have not been proven to be safer or more
effective in treating the same condition as the first-line drugs, and their cost is considerably greater. Your provider will
assist you in determining if your current drug requires step therapy.
If you currently take any of the mentioned medications, please contact your prescribing provider immediately to
discuss alternatives or initiate the required authorization process.
*PersonalCare’s prior authorization list is subject to change throughout the plan year.
Prior authorization criteria and forms are available on PersonalCare’s website (www.PersonalCare.org).
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