Formulary Frequently Asked Questions (FAQs)

Q: What is the Optimum HealthCare Formulary?
A formulary is a list of covered drugs selected by Optimum HealthCare, in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Optimum HealthCare will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Optimum HealthCare network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Q: Can the formulary change?
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 that 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. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-share for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary, add prior authorization criteria, 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 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug. If the Food and Drug Administration 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.

Q: What about Generic Drugs?
Optimum HealthCare covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

Q: What if my drug isn't on the formulary?
If your drug is not included on this formulary, you should first contact Member Services and confirm that your drug is not covered. If you learn that Optimum HealthCare does not cover your drug, you have two options:

  1. You can ask Member Services for a list of similar drugs that are covered by Optimum HealthCare. When you receive the list, share it with your doctor and ask him or her to prescribe a similar drug that is covered by Optimum HealthCare.
  2. You can ask Optimum HealthCare to make an exception and cover your drug.

Find out more about requesting an exception:   2024

Please contact us to find out more information about our formulary drug coverage.

Coverage Determination/Tier Exception form

Last updated 10/01/2023