Avera Health Plans is pleased to offer a variety of pharmacy benefit options available in many of our new plans.
If you are a member or provider, you must log in to find out what your specific plan covers for pharmacy benefits and what medications or services require a preauthorization.
The information provided on our website is a general reference of our pharmacy benefits. Not all plans or members will use these pharmacy programs listed below..
Our Drug Formulary is a list of prescription medications that contains both generic and brand-name medications that have been approved by the U.S. Food and Drug Administration (FDA).
Individual and Small Employer Plans
New individual plans and small employer plans have a 6-tier drug formulary plan:
Large Employers and Older Plans
Large employers and some of our older plans (prior to 2014) will have an option of a 3-tier drug formulary plan:
Medication Search Tool
The following link will allow you to search and identify if a medication will be covered with one of our new individual plans:
Small employers can provide the same 6-tier plan for coverage.
NOTE: You can identify the tier by reviewing the Summary of Benefits and Coverage of the new plan. It is found on page 3.
Other medication search tools for older plans or large employer plans can be found using our 3- and 4-Tier Medication Search Tools:
Benefits vary based on plan design and individual benefits. Benefit determinations are based on the member’s plan selection. Exclusions, limitations or exceptions may apply. NOTE: Please log in to identify preauthorization requests associated with your benefits. (Login links are also located on the top right of our website.)
- List of medications requiring Medical Prior Authorization (pdf)
- List of medications requiring Pharmacy Prior Authorization (pdf)
Not all injectable medications are covered on the pharmacy benefit. The injectable medication must be considered self-injectable which means you are able to give yourself the medication safely without risk. If the injectable medication is not considered self-injectable, the medication may be covered under the medical benefit.
Specialty medications treat chronic, complex conditions such as hepatitis C, multiple sclerosis, cancer and rheumatoid arthritis. These medications tend to be higher in costs and require special storage and handling. Avera Health Plans has a network of specialty pharmacies available to assist you with specialty medication needs.
- Step Therapy Programs (pdf)
Step therapy is intended to use the most cost-effective and safest medication available for a specific medical condition. Step therapy programs require your provider to prescribe Step One medication before Step Two medication.
Please use our Pharmacy Locator tool to find a participating pharmacy near you.