For certain prescription drugs, special rules restrict how and when we cover them. A team of doctors and pharmacists made these rules to:
- Help you use drugs in the way that works best.
- Help control overall drug costs, which keeps your premium lower.
- Encourage you and your provider to use a lower-cost option when possible that:
- Works for your condition; and
- Is just as safe.
What are prescription drug rules?
If there is a rule for your drug, it means that you or your provider will have to take extra steps in order for us to cover the drug. If you want us to waive the rule for you, you will need to use the exception request process. We may or may not agree to waive the rule for you.
You or your doctor can view the Drug Formulary on our website to see which, if any, rules apply to each drug.
- Prior Authorization - Doctors must get PA for some drugs. Any corresponding supplies or equipment also require PA. It promotes appropriate, cost-effective use.
- Quantity Limits - We limit the amount of some drugs. These drugs, if taken inappropriately, could be unsafe and cause side effects. All specialty drugs are limited to 30-day supplies.
- Step Therapy - Step therapy means that you try one or more other drugs before we cover this drug.
Click here to find your drug formulary.
Health Plan Materials
To find out what your cost share is, see your plan’s material.
Medicare Advantage (Evidence of Coverage)
State of Oklahoma Group Retirees (Evidence of Coverage)
Federal Employees Health Benefits (Brochure)
State, Education, and Local Government (Member Handbook)
Commercial Group (Member Handbook)