skip to main content

Text/HTML


Formularies

Text/HTML

Formularies

Preferred Drug List
Group Benefits Program - Plan Year 2017

The drug formulary is updated each quarter.

Your health plan includes a three-tier prescription drug benefit, which is administered by Scott & White Health Plan and our Pharmacy Benefit Manager (PBM) in accordance with the plan design specified by the Employees Retirement System of Texas (ERS).

  • A 30-day supply of non-maintenance Tier 1 drugs are covered at a $10 retail copay; Tier 2 drugs are covered at a $35 retail copay; and Tier 3 drugs are covered at a $60 retail copay.
  • A 30-day supply of maintenance Tier 1 drugs are $10; Tier 2 drugs are $45; and Tier 3 drugs are $75.
  • Mail order copays for up to a 90-day supply are $30 for Tier 1 drugs; $105 for Tier 2 drugs; and $180 for Tier 3 drugs.

Please note that there is a $50 per enrollee plan year deductible (September 1 - August 31). If a brand-name medication is dispensed when a generic is available, you will be responsible for the generic copay plus the cost difference between the generic and the brand-name medication.

Your prescription benefit plan design may not cover certain categories of drugs, regardless of their appearance in this document. Check your Evidence of Coverage (pdf, 1.4mb) or contact Scott & White Health Plan's Member Services Department for those conditions and medications not covered by your plan.  The preferred list of covered drugs is subject to change. When new drugs become available during the year or the Pharmacy and Therapeutics Committee meets, drugs may move from one copay tier to another.

This document lists some commonly used preferred and non-preferred drugs in alphabetical order; it does not contain a complete list of all preferred and non-preferred drugs. If you don't find your medication listed in this guide, you should contact Scott & White Health Plan's Member Services Department. Do not contact ERS for assistance with your medications.

PA Indicates Prior Authorization    
QL Indicates quantity limit
ST Indicates step therapy
* Indicates maintenance medication

Lowercase Names = Tier 1
Uppercase Names (B) = Tier 2
Uppercase Names (C) = Tier 3

* Maintenance drugs are coded as such if they meet the following criteria:

  • Medications that do not require frequent monitoring and dosage adjustments for side effects or therapeutic responses. Certain drugs that may have potential life threatening toxicity when taken as an intentional overdose may be excluded.
  • Medications that are used to treat a chronic condition with no therapy endpoint. These drugs are taken continuously but do not provide a cure for the condition being treated.
  • Medications that are typically used as outpatient-type drugs.

Note: The Formulary Lists are in Adobe® Acrobat (PDF) format. You may download the current Adobe® Acrobat Reader here.

Copay and Deductible Information