Drug Formulary Frequently Asked Questions

Pharmacy Services

What is a Formulary?

The formulary is a list of covered and preferred brand and generic drug products for HometownRx members. The drug list includes drugs used to treat common diseases or health problems. A team of doctors and pharmacists (Pharmacy and Therapeutics (P&T) Committee) meets quarterly to decide which drugs should be on the drug list. The P&T Committee reviews new and existing drugs and chooses drugs that work best and are proven to be safe. Consequently, the formulary is updated regularly and subject to change without notice. The formulary is a good source for you and your provider to determine the best drug for your condition, at the lowest out-of-pocket expense to you. Ultimately, specific drug product selection for an individual member is dependent on your prescriber.

Benefit Coverage and Limitations Q&A

What is an excluded medication?

Certain drug products have been excluded from this formulary. If you choose to use an excluded drug product Hometown Health may not reimburse for these drug products and may require you to pay 100% of the cost. Furthermore, if you choose to use a drug that is not on formulary or excluded, the cost, does not accumulate towards meeting your annual deductible or out of-pocket maximums.

Why might a medication be excluded?

Certain classes of medication are not covered under your pharmacy benefit. These medication classes may include but are not limited to: non-FDA approved drugs, over the counter (OTC) medications, drugs to treat impotency or sexual disorders, fertility agents, weight loss drugs, hematinics, reusable needles, disposable syringes, ostomy supplies, infant formulas, dietary supplements, hypopigmentation agents, diagnostic agents, cosmetic medications, and compounded medications.

Why might a medication be excluded?

How do I know if a medication will apply to my pharmacy benefit?

The formulary applies only to outpatient drugs provided to members, and does not apply to medications used in inpatient settings. If an inpatient medication has been prescribed your doctor must contact Hometown Health customer service to obtain benefit coverage information specific to your plan design for your medical benefits.

What if my drug is not listed on the formulary?

To avoid delays in access to your treatment, your provider may check the formulary to prescribe a covered drug that is best for you. The Hometown Health formulary offers a wide coverage of available drugs. However, in instances where the drug is rejected due to “Drug Not Covered”, you may either:

Ask your pharmacy to contact your provider to change the prescription to a covered formulary alternative.
If your provider believes the non-covered product is “medically necessary” for your condition, your provider may request an “Exception” for coverage. See the next section for information on how to request an exception.

How do I request an exception?

Members or providers can ask HometownRx to make an exception to our coverage rules. Exceptions are reviewed for medical necessity, your inability to use covered drugs (e.g., side effects, contraindications, allergies), current covered products may not be effective for you, and new drug entrants that have not yet been reviewed and placed on the formulary. Reviews will consider superiority of the request over current covered options.

What can I expect to pay?

What you expect to pay depends on the type of drugs your provider ordered for you. Each drug is placed in a tier level; different tiers represent the different levels of payment for covered medications. Tier structures are developed to encourage you to use quality products at the most cost-effective option to you. The lower cost option does not represent a lower quality product. Rather it is the best cost option considering covered products within that treatment category. You can be assured that drugs provided through your pharmacy benefit has been through rigorous processes to be approved by the FDA.

Tier 1: This tier represents lowest out-of-pocket expense. This tier includes select generics.
Tier 2: This tier represents the next lowest out-of-pocket expense. This tier generally includes preferred brands, but may also include select generics.
Tier 3: This tier represents a moderate out-of-pocket expense. This tier includes nonpreferred brands and non-preferred generics (typically have similar alternatives at a lower tier level).
Tier 4: This tier represents the highest out-of-pocket expense and is reserved for Specialty Medications/Injectable medications. This tier includes brands and nonpreferred high cost generics medications.
Tier 5: This tier represents the preventive medications available to you at no cost under the Affordable Care Act (ACA) – Essential Health Benefits (EHB) and are not subject to deductibles. Coverage of any listed medications including over-the-counter (OTC) medications requires a prescription from your health care provider. Certain age restrictions may apply.

Why are there generics on different tiers?

With the increases in availability of high cost specialty drugs and slowed developments of new active ingredients in the traditional drugs, some older drugs have been reformulated to create a new brand drug, or some generics have been rebranded by other companies to offer the same active ingredient drugs at a higher cost than previous generics. Although our tier structure still remains with most generics in the lower cost tiers, the high cost generics with lower cost alternatives may be moved to the higher cost tiers to encourage you to use the more cost effective options.

How can I save on prescriptions?

Here are some other tips to pay less out of pocket for your prescription drugs:

Ask your provider to consider prescribing generic drugs instead of brand-name drugs, and whether the generic drug is right for you.

Ask your provider to consider prescribing drugs that are on the Hometown Health Formulary.
Check to see if your plan includes our mail-order pharmacy service. Depending upon your plan, mail order may save you money.
Check drug prices at different in-network pharmacies on MyChart.