Tier 4 Prescription Drugs

Search for medications on Avera Health Plans 4-Tier Formulary, which include preferred name-brand drugs. Your out-of-pocket costs will be higher than drugs in lower tiers.

What is a drug formulary?

What is a drug formulary?

The drug formulary lists include both generic and brand-name medications approved by the U.S. Food & Drug Administration (FDA). It includes covered prescription drugs approved for use for specific treatments and dispensed through participating pharmacies. Avera Health Plans works with a team of health care providers to choose drugs that provide quality treatment. We cover drugs on the drug formulary that are:

  • Medically necessary
  • Approved by the FDA
  • Filled at a participating pharmacy

Current Members

If you already have health insurance with Avera Health Plans, log in to access details on your pharmacy benefits – and to determine if certain medications or services require a preauthorization.

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PHARMACY COVERAGE

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4-Tier Drug Formulary Search

Not a Member Yet? If you’re not an Avera Health Plans member yet, check out this list of commonly covered drugs (the formulary) from the selections below.

Important: Drug formularies change periodically. Only use this list to identify whether a prescription is an approved drug in the 4-Tier benefit plan.

DOWNLOAD 4-TIER DRUG FORMULARY (pdf)

Drug Formulary Search

Member Pharmacy Questions

We have answers on questions members frequently ask about pharmacy benefits. Learn more about pharmacy coverage in our member resources.

How much will I pay for prescriptions?

How much will I pay for prescriptions?

The amount you pay for your prescription depends on the drug's tier level and the benefit level shown on your Summary of Benefits and Coverage (see page 3).

How do I request an exception to the drug formulary?

How do I request an exception to the drug formulary?

You can ask Avera Health Plans for an exception to the benefit coverage rules. To request a drug formulary exception:

  1. Go back to your secured login page, My Pharmacy.
  2. Click the link to request a drug formulary exception.
  3. Complete the online form and submit.

For urgent requests, determination will be made no more than 24 hours after the request is received. For standard request, determination takes 72 hours.

Generally, we will only approve the exception request if you’ve tried alternative drugs available on the drug formulary and they haven’t been effective for treating your condition and/or would cause adverse side effects to you if you were to try them.

Why did the pharmacy decline my prescription request?

Why did the pharmacy decline my prescription request?

There are multiple reasons why a prescription may be declined. If you have questions, contact us so we can look into your records and provide an explanation for the pharmacy declining the request.

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Have a question or looking to pay your premium? Go to our member resources for answers, benefit information and much more.

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