BLUE RX ESSENTIALS^SM

Welcome

We cover both brand name drugs and generic drugs. Generic drugs have the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs. Members may be required to pay more for a prescription when a brand-name product is dispensed.

What is a Formulary?

A formulary is a list of covered drugs which represents the prescription therapies believed to be a necessary part of a quality treatment program. We will generally 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. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

Plan Name	Tier Designation
Wellmark Bronze Traditional Wellmark Silver Traditional Wellmark Gold Traditional Wellmark Bronze HDHP Wellmark Bronze Primary Care Wellmark Silver Primary Care Wellmark Gold Primary Care	Tier 1	Tier 2	Tier 3	Specialty Biosimilars & Specialty Generics Tier	Specialty Preferred Tier	Specialty Non-Preferred Tier
Wellmark Standard Bronze Wellmark Standard Silver Wellmark Standard Gold	Tier 1	Tier 2	Tier 3	Specialty Drug Tiers (biosimilar, generics, preferred, and nonpreferred)

Printable Files

To view a version of your Formulary Drug List with a screen reader, please click Printable Formulary below.

The following files require Adobe Acrobat. Download Adobe Acrobat

• Printable Formulary
• Prior Authorization

How to Search For Drugs

• Use the alphabetical list to search by the first letter of your medication.
• Search by typing part of the generic (chemical) and brand (trade) names.
• Search by selecting the therapeutic class of the medication you are looking for.

How to Request an Exception

You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make:

You can ask us to cover your drug even if it is not on our formulary.

You can ask us to waive coverage restrictions or limits on your drug.

You can ask us to provide a higher level of coverage for your drug.

You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception. When you are requesting a formulary, tiering or utilization restriction exception you should submit a statement from your physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescribing physician’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 72 hours after we get your prescribing physician’s supporting statement.

Common Drug Exclusions

Due to benefit design parameters, some plan sponsors may choose to exclude certain drug classes. Prior authorization is generally not available for drugs that are specifically excluded by benefit design. Common excluded drugs may include, but are not limited to:

• OTC drugs or their equivalents unless otherwise specified in the formulary listing.
• Drug products used for cosmetic purposes
• Experimental drug products, or any drug product used in an experimental manner
• Replacement of a lost or stolen drug
• Foreign drugs or drugs not approved by the United States Food & Drug Administration (FDA)

Notice of Nondiscrimination

• Español   |
•   中文   |
•   Tiếng Việt   |
•   Hrvatski   |
•   Deutsch   |
•   اللغة العربية   |
•   ລາວ   |
•   한국어   |
•   हिंदी   |
•   Français   |
•   Pennsylvaanisch Deitsch   |
•   ไทย   |
•   Tagalog   |
•    unDusdm    |
•   Русский   |
•   नेपाली   |
•   አማርኛ   |
•   Nasarare   |
•   Afaan Oromo   |
•   Український   |
•   Diné