A formulary is a list of covered prescription drugs and includes both generic and brand drugs. The Farm Bureau Health Plans formulary was developed by a team of doctors and pharmacists, and must meet requirements set by Medicare.
The formulary will indicate what tier each drug is in and will indicate if there are any restrictions and/or limitations for each drug.
Each drug on the formulary is in one of following five cost-sharing tiers:
- Tier 1 – Preferred Generic – Includes lower-cost, commonly used generic drugs.
- Tier 2 – Generic – Includes many generic drugs.
- Tier 3 – Preferred Brand – Includes many common brand name drugs, called preferred brands and some higher-cost generic drugs.
- Tier 4 – Non-Preferred Brand – Includes non-preferred generic and non-preferred brand name drugs. In addition, Part D eligible Compounded Medications are covered in Tier 4.
- Tier 5 – Specialty Tier – Includes unique and/or very high-cost drugs.
2023 Farm Bureau Advantage Formulary - Central Tennessee
2023 Farm Bureau Advantage Formulary - Knoxville Tennessee
2023 Farm Bureau Advantage Formulary - Tri-Cities Tennessee
Drug restrictions and limitations
For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed the drug list and rules to help ensure safe, effective, and affordable drug use.
If there is a restriction for your drug, it usually means that you (or your doctor) will have to use the coverage decision process to ask us to cover the drug.
Restrictions may include:
Prior Authorization (PA)
The plan requires you or your doctor to get prior authorization for certain drugs. This means the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. If you don't get approval, the plan may not cover the drug.
Quantity Limits (QL)
The plan will cover only a certain amount of this drug for a single copay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you or your doctor can ask the plan to cover the additional quantity.
Step Therapy (ST)
There may be effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you or your doctor can ask the plan to cover this drug.
Medicare Part B or Medicare Part D Coverage Determination (B/D)
Depending on how a drug is used, it may be covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure it's correctly covered by Medicare.
NOTE: If you do not get approval from the plan for a drug with a restriction or limit before using it, you may be responsible for paying the full cost of the drug.
Types of Drugs Not Covered
Medicare excludes certain prescription drugs from coverage. If you get a drug that is excluded by Medicare, you will be responsible for the full cost of the drug. Drugs generally not covered by Medicare prescription drug plans include, but are not limited to,:
- Drugs covered by Medicare Part A and/or Part B.
- Drugs purchased outside of the U.S. and its territories.
- Off-label use of a drug.
- Over-the-counter drugs.
- Drugs used for cosmetic purposes or to promote hair growth.
- Drugs used to treat sexual or erectile dysfunction.
Review the Evidence of Coverage for a list of drug types not covered by Medicare prescription drug plans.