AffirmedRX
Understanding Your Medication Changes
See what the changes listed in the Pre-Enrollment Tool mean and what conversations you may need to have with your prescriber next.
1. Tier Change
What this means:
This medication will remain on the formulary and is still eligible for coverage, but it is moving to a different cost-sharing tier. Your out-of-pocket costs may change.
What you need to do:
Review your new cost share and talk to your prescriber about lower-cost covered alternatives if necessary.
2. New Quantity Limit
What this means:
This medication will remain on the formulary and is still eligible for coverage, but there is a limit on the quantity covered by your plan.
What you need to do:
Talk to your prescriber about the quantity limits on your medications. If your current dose exceeds the covered limit and is medically necessary, your prescriber can submit a Quantity Limit exception request for review.
3. New Step Therapy Requirement
What this means:
This medication will remain on the formulary and is still eligible for coverage, but now requires you to first try a preferred medication (Step Therapy) before it can be covered under your plan.
What you need to do: Talk to your prescriber about the available preferred medications. If Step Therapy is not
appropriate for you, your prescriber can submit a Step Therapy exception request for review.
4. New Prior Authorization Requirement
What this means:
This medication will remain on the formulary and is still eligible for coverage, but prior authorization is required before it can be covered under your plan
What you need to do: Talk to your prescriber about your medications that require prior authorization. If you need to continue this medication, your prescriber must submit a Prior Authorization
request for review.
5. Non-Formulary with Medical Exception
What this means:
This medication is being removed from the formulary and will no longer be covered under your plan without an approved medical exception. Other covered medications
may be available.
What you need to do: Talk to your prescriber about switching to a covered alternative. If there are no covered alternatives and this medication is still medically necessary for you, your prescriber can submit a Medical Exception request for continued coverage for review.
6. Excluded Drug
What this means:
This medication is being removed from the formulary and will no longer be covered under your plan.
What you need to do: Talk to your prescriber about switching to a covered alternative. If you continue taking
this medication, you will be responsible for the full cost.