6-Tier Drug Formulary Search

With this search tool, you can identify whether or not a specific drug will be covered by a plan with 6-tier coverage. Only use the search function below to identify if a prescription is an approved drug in a 6-tier benefit plan.

*Note: Drugs listed on the drug formulary do not guarantee coverage on the member's pharmacy benefit plan. Utilization management edits (for example: quantity limits, step therapy or preauthorization requirements) may not apply to all pharmacy benefit plans.

Coverage of a drug is subject to the limitations applied to the pharmacy benefit. Members should contact our service center to determine specific coverage and utilization management edits.

Reviewed by LS on August 16, 2018

Pharmacy FAQs

What is a Drug Formulary?

A drug formulary is a list of prescription drugs under a benefit plan, which are approved for use for specific treatments and dispensed through participating pharmacies to members. The drug formulary changes periodically. Your plan covers both brand and generic drugs. Generic drugs have the same active ingredient as the brand name drug.

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?

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

  • Go back to your secured login page, My Pharmacy
  • Click on the link to request a special drug
  • Complete the online form and submit
  • Determination will be made no later than 24 hours (after the request is received) for expedited requests and 72 hours for standard requests

Generally, we will only approve the exception request if the alternative drugs available on the drug formulary have been tried and are not 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 request for a prescription?

There are multiple reasons and it is important to call our Service Center toll-free at 1-888-322-2115, Monday - Friday, 8 a.m. - 5 p.m. CT so we can look into your records and provide an explanation for the pharmacy declining the request. Or email Ask@AveraHealthPlans.com, provide a phone number to be reached and someone will contact you.

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