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Understanding your health plan’s comprehensive drug formulary

Posted March 25, 2021 by Charles A. Zonfa, MD, FACOG | Chief Medical Office

A drug formulary is a list of all drugs, both generic and brand name, that are covered by your health plan. The purpose of the drug formulary is to direct members to the least costly medication that is most effective in treating their condition.

So whether you are taking prescription drugs temporarily for an infection or you take them regularly for a chronic illness, it’s important to understand your heath plan’s drug formulary so you’re prescribed a covered medication.

You may only receive coverage for medications included on this preferred list and you could pay more if you and your doctor choose a drug that is not included on it.

SummaCare understands the important role prescription drugs play in keeping us all healthy. Learn more about our drug formulary to ensure you’re covered.

What is SummaCare’s comprehensive drug formulary?
Our comprehensive drug formulary is a list of all covered drugs selected by SummaCare in consultation with a team of healthcare providers. The formulary represents the prescription therapies believed to be a necessary part of a quality treatment program.

SummaCare covers both brand name and generic drugs, which tend to cost less than brand name drugs. Generic drugs have the same active-ingredient formula and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.

In most cases, SummaCare will cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a network pharmacy and other plan rules are followed.

Can the drug formulary change?
Yes. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least before the change becomes effective, or at the time the member requests a refill of the drug.

Generally, if you are taking a drug on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released.

If the FDA deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.

Does the drug formulary have restrictions?
Yes. Our drug formulary indicates if a drug has limitations, such as prior authorization, step therapy or quantity limits. Find out what is required should your medication have one of these limitations:

  • Prior authorization: If prior authorization is required for a medication, your prescribing physician will need to call the number on your SummaCare ID card and supply clinical information regarding the medical necessity for the requested drug.
  • Step therapy: Step therapy is the practice of beginning drug therapy for a medical condition with the most cost-effective and safest drug therapy and progressing to other more costly or risky therapies, only if necessary. If a step therapy protocol is in place for a medication, claims for this medication will be covered based on the member’s previous medication history. If prior medication history does not meet clinical guidelines, the prescribing physician will need to call the number on your SummaCare ID card and supply clinical information regarding the medical necessity of the requested drug.
  • Quantity limits: If quantity limits (maximum number of tablets/capsules, per retail prescription) are in place for a medication and your prescribing physician is requesting a quantity in excess of SummaCare’s limit, he/she will need to call the number on your SummaCare ID card to supply clinical information supporting the medical necessity of the increased quantity.
  • Opioid Edits: SummaCare has implemented the following opioid edits:
  • Enhanced Opioid Cumulative Dosing: This limit is based on MME (Morphine Milligram Equivalent), which is the calculated amount of opioids that you are taking per day. Your opioid prescription will deny at the pharmacy if your total MME is greater than 80 MME. This means that you will need to get approval from SummaCare to fill your opioid prescription(s).

    Days Supply Limit Edit: If the course of your opioid treatment continues for more than a 90 days then your opioid prescription will deny at the pharmacy. If you need more than a 90 day supply, you will need to get approval from SummaCare to fill your opioid prescription.

    Does the drug formulary include specialty drugs?
    Yes. Depending on your plan, specialty drugs are indicated on the formulary with an asterisk (*) or they may be in their own specialty tier. Specialty drugs are expensive prescription drugs that require special handling and storage, and they are not always readily available at a retail pharmacy. Specialty drugs are used to treat chronic or genetic conditions, such as multiple sclerosis, psoriasis, rheumatoid arthritis and viral hepatitis.

    Most specialty drugs require prior authorization. SummaCare prescription drug benefits limit specialty drugs to a 30-day supply and will only cover them when filled through our contracted specialty pharmacy.

    What if my drug is not on the formulary?
    If you are prescribed a drug that is not listed on the formulary, you can ask us to make an exception. Your prescriber will need to tell us why making an exception is medically necessary for you. If the exception is approved, this drug will be covered at a predetermined cost-sharing level. Generally, SummaCare will only approve your request for an exception if the alternative drugs included on the formulary would not be as effective in treating your condition and/or would cause you to have adverse medical effects. Your prescriber must submit a supporting statement by completing the Provider Individual and Group MedImpact Medication Request form, which is available on our website at, under the Find a Document section. The Medication Request can be sent via phone, mail or fax to:

    MedImpact Healthcare Systems, Inc.
    10181 Scripps Gateway Court
    San Diego, CA 92131
    Phone: 800-788-2949
    Fax: 858-790-7100

    How can I find which pharmacies are included in my plan?
    Use SummaCare’s Find Your Pharmacy tool to search and find pharmacies near you that are located in our network.

    For more information about our comprehensive drug formulary, call the SummaCare customer service number located on the back of your SummaCare Member ID card.


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