How is the Formulary Developed?

Unity’s Pharmacy & Therapeutics (P&T) Committee creates and updates the prescription drug formulary. This committee is made up of doctors and pharmacists who care for Unity members. The P&T Committee meets every month to review medications. They decide the formulary status and restriction status of each medication. A variety of factors are considered. They include safety, side effects, drug interactions, how well the drug works, dosing schedule and dose form, appropriate uses and cost-effectiveness.

In making formulary decisions, the committee uses the most up-to-date information on the medication from a variety of sources. These include published clinical trials, data submitted to the Food and Drug Administration (FDA) for drug approval and recommendations from local or national treatment guidelines. Additionally, the committee asks for information from local health care practitioners who are experts in the use of the drug class under review.

How often does Unity’s Prescription Drug Formulary change?

The Formulary is updated monthly. Most changes involve adding new drugs or drugs that are newly available in generic form. At times, drugs are removed from the formulary or moved to restricted status. Check the website or request an up-to-date version from Unity Customer Service.

Quarterly formulary updates are listed on the formulary page on the website.

What happens when a drug I’m taking has a change in its formulary status?

If your drug changes from ​preferred to non-preferred, your coverage continues at a Tier 3 copay. In other words, your copay will be higher, but you will not pay the full cost of the drug. If you want to keep your copay at the same level, ask your doctor to find a similar formulary drug. If you have had a recent claim for the medication as a Unity member, you and your practitioner will receive a notification of the formulary change and your options BEFORE the change occurs. You will be given sufficient time to discuss your options with your practitioner and make a decision. You generally have two options –

  1. Continue taking the drug at the Tier 3 copay level
  2. Switch to an appropriate ​preferred version of the medication to receive coverage at the preferred copay level
What happens when a drug I am taking is changed to restricted status?

If you are taking a drug that becomes restricted, your coverage may change in one of two ways. The change is based on the type of drug and the nature of the disease it treats.

  1. You will continue to receive coverage for the drug from Unity. This happens when the P&T Committee believes that it is not safe to stop taking the medication. Another reason is that sometimes switching to another medication is complex and difficult. In either case, your coverage for the drug will continue without the need for Prior Authorization. Only patients who are new to the drug after it becomes restricted need Prior Authorization to receive coverage.
  2. Coverage for the newly restricted drug will end and a different medication will be suggested. You and your doctor will be notified before the restriction occurs. You will both be given information about similar drugs that are not restricted. In general, you have three choices to review with your doctor.
    • Switch to a similar formulary drug that does not require Prior Authorization. This drug will be covered at the formulary copay level
    • Ask your doctor to request Prior Authorization for continued coverage of the restricted drug
    • Continue taking the restricted drug without coverage (you pay the full cost)
How do I make sure the medicine my doctor gives me is at the lowest copay?

Before your doctor writes a prescription, tell your doctor that you prefer generic or Unity formulary drugs if possible. That will help the doctor find the drugs with the lowest copay.

If your doctor gives you drug samples to start treatment, it’s best to find out if that specific drug is on Unity’s Formulary. Starting with samples does not mean that the drug will be covered or have the lowest possible copay.

Why does Unity only pay for a one-month supply of medication at a time?

First, covering just one month of medication reduces waste. Drugs are often switched or the dosage changes. Even medications that you have been taking for a long time may unexpectedly change. Proper disposal of unused drugs is difficult, so it’s best to have less to throw away.

Second, Unity wants to keep costs down for active members. A one-month supply doesn’t allow stockpiling of medication by those who are planning to end their membership.

If the medication you take is considered a chronic medication, it may qualify for the Choice90 program.

How are drugs classified as generic or brand?

When patented new drugs enter the market, they are called brands. These branded drugs are protected by patents that last up to 17 years. They are usually more expensive. After the patent expires, other companies can make drugs with the same active ingredients. These drugs are called generics, and they are usually cheaper.

The first version of a medication on the market is usually called “the brand.” An example is Prozac, which is another name for the drug fluoxetine. After the Prozac patent expired, other companies are marketing versions of the medication. These versions are called “generics.”

Determining brand / generic status is not always easy. The P&T committee uses a national database of medication-related information called the First Data Bank National Drug Data File. The brand or generic status of a medication as listed in First Data Bank determines whether that medication is considered a generic or a brand on Unity’s Prescription Drug Formulary.