We require generic substitution on the majority of products when a generic equivalent is available. Generic substitution is a pharmacy action whereby a generic equivalent is filled rather than the brand name product. If a brand name drug is filled when a generic equivalent is available, you will be required to pay the difference between the contracted cost of the generic and brand name drug in addition to the copay. Some branded alternatives are excluded from coverage.
For some drugs, your doctor or other prescriber must get approval from Sierra Health and Life before you fill your prescription. If you don’t get approval, we may not cover the drug.
You may be required to try step therapy. This means you must try certain drugs to treat your medical condition before we’ll cover another drug for that condition. If your doctor thinks the first drug doesn’t work for you, your doctor may submit an exception request to waive step therapy requirements or quantity limit restrictions.
Sometimes we limit the amount of a drug you can get. Your doctor or other prescriber must get approval from us if the quantity being requested is higher than this limit.
Some drugs are only approved for specific age ranges. Your doctor or other prescriber must get approval from Sierra Health and Life if you are younger or older than the age limitation.
Some drugs are only approved for specific diagnoses. If your pharmacist submits an appropriate diagnosis along with the insurance claim, it will pay. Or, your doctor or other prescriber may get approval from Sierra Health and Life if the requested drug is for the required diagnosis.
Specialty pharmacy drugs need to be accessed through the preferred specialty pharmacy, Optum Specialty Pharmacy (formerly BriovaRx). Specialty pharmacy drugs may require extra handling, provider coordination or patient education that can’t be done at a network retail pharmacy.
We require patients that are new to therapy with some specialty pharmacy drugs to fill only a 15-day supply at a time for the first 90 days. Optum Specialty Pharmacy (formerly BriovaRx) will contact these patients each time prior to filling the 15 day supply to confirm if they are tolerating the drug. After 90 days have passed, Optum Specialty Pharmacy (formerly BriovaRx) will then be able to fill up to a 30 day supply at a time.
Preferred generic and brand name medications are available at the Tier 1 and Tier 2 copay. Non-preferred medications, as well as some medications not listed on the preferred drug list (PDL), are also covered but for a higher Tier 3 or Tier 4 copay.
Some drugs are excluded from coverage and are not covered even if your doctor or other prescriber requests approval. Excluded drugs will not be found on the preferred drug list (PDL). Some examples of excluded drugs include drugs used for weight loss or to promote fertility, drugs covered in another formulation or over-the-counter medications.