Elite Rx 2022 Formulary (List of Covered Drugs)
Formulary (List of Covered Drugs) (PDF) (updated 12/1/22)
Prior Authorization Criteria (PDF) (updated 12/1/22)
Aspirus Formulary Exception Criteria (PDF) (updated 1/21/22)
Part B Medical Injectable Drug Authorization List (PDF) (updated 11/15/22)
Formulary Change Notice (PDF) (updated 8/18/22)
| Tier | Deductible | 30-Day Supply - Preferred Cost Share |
30-Day Supply - Standard Cost Share |
90-Day Supply - Preferred Mail Order |
| Tier 1 Preferred generic drugs |
Deductible does not apply | $2 copay | $7 copay | Two preferred copays |
| Tier 2 Generic drugs |
Deductible does not apply | $10 copay | $16 copay | Two preferred copays |
| Tier 3 Preferred brand drugs |
$295 | $47 copay | $47 copay | Two preferred copays |
| Select insulins | Deductible does not apply to select insulins | $30 | $35 | Two preferred copays |
| Tier 4 Non-preferred drugs |
$295 | 50% coinsurance | 50% coinsurance | 50% coinsurance |
| Tier 5 Specialty drugs |
$295 | 27% coinsurance | 27% coinsurance | 27% coinsurance |