Elite Rx 2023 Formulary (List of Covered Drugs)
Formulary (List of Covered Drugs) (PDF) Updated 12/1/2023
Prior Authorization Criteria (PDF) Updated 12/1/2023
Step Therapy Criteria (PDF) Updated 3/1/2023
Aspirus Formulary Exception Criteria (PDF) Updated 1/21/2022
Formulary Change Notice (PDF) Updated 8/1/2023
Part B Medical Injectable Drug Authorization List (PDF) Updated 9/20/2023
Diabetic Supplies List (PDF) Updated 5/1/2023
| 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 |
$245 | $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 |
$245 | 50% coinsurance | 50% coinsurance | 50% coinsurance |
| Tier 5 Specialty drugs |
$245 | 29% coinsurance | 29% coinsurance | 29% coinsurance |
Important Message About What You Pay for Vaccines - Our plan covers most Part D vaccines at no cost to you, even if you haven’t paid your deductible. Call Customer Service for more information.
Important Message About What You Pay for Insulin - You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on, even if you haven’t paid your deductible.