Check Our Drug Lists
The cost of prescription drugs varies widely, even for medications that are used to treat the same condition. Our medication guide/formulary was developed to help you select lower cost options that can save you money. What is a formulary?
If you receive coverage through an employer, contact your administrator to see which drug program applies to you. The drugs listed in the formulary and utilization management requirements may not apply to all employer group benefits.
The formulary may change at any time. You will receive notice when necessary.
Check Drug Prices for Your Plan (requires log in)
2018 Drug Lists
- Univera SeniorChoice Basic (HMO)
- Univera SeniorChoice Secure (HMO-POS)
- Univera SeniorChoice Value (HMO)
- Univera SeniorChoice Value Plus (HMO-POS)
- Univera SeniorChoice (HMO-POS) - through Employer or Group
- Univera Medicare PPO - through Employer or Group
The Formulary may change at any time. You will receive notice when necessary.
Existing Members: Request to receive a printed Drug Formulary by mail
For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the safest, most effective way and also help us control drug plan costs. A team of doctors and/or pharmacists developed these requirements and limits for our Plan to help us provide quality coverage to our members. Please consult our formularies for more information about these requirements and limits.
- Prior Authorization
Certain medications require prior authorization. This means we must give our approval before you fill your prescriptions. If you don't get approval, the drug may not be covered.
- Step Therapy
In some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
- Quantity Limits
For certain drugs, we limit the amount of the drug that we will cover. For example, we provide 30 tablets per 30-day supply for Xarelto. Drugs that have quantity limits are indicated on our formulary. Generally, the amount of drug we cover is based on Food and Drug Administration (FDA) approved dosing and usage guidelines. The same Quantity Limits requirements apply to both mail order and retail pharmacies.
Drugs that require Prior Authorization, Step Therapy or Quantity Limits are indicated on our drug list. Consult our formularies to see if your medication requires Prior Authorization, or Step Therapy.
You can ask us to make an exception to our coverage rules, including waiving our prior authorization, step therapy and quantity limit restrictions on your drug. Learn more about Requesting an Exception below.
If you want to request coverage of a drug not on our formulary, a waiver of our utilization management requirements or your cost-sharing amount, you can request an exception.
- Call our Customer Service Department to request an exception to our coverage rules.
- What is an exception?
An exception is a type of initial determination (also called a "coverage determination") involving a Part D drug. You, your doctor or other prescriber may ask us to make an exception to our Part D coverage rules in a number of situations.
- You may ask us to cover your Part D drug even if it is not on our formulary. Excluded drugs cannot be covered by a Part D plan unless coverage is through an enhanced plan that covers those excluded drugs.
- You may ask us to waive coverage restrictions or limits on your Part D drug. For example, for certain Part D drugs, we limit the amount of the drug that we will cover. If your Part D drug has a quantity limit, you may ask us to waive the limit and cover more.
- You may ask us to pay a lower price for a covered non-preferred Part D drug through the tiering exception process. If your Part D drug is on our non-preferred tier (Tier 4 - non-preferred drug), you may ask us to cover it at the cost-sharing amount that applies to drugs in the preferred tier (Tier 3 - preferred drug). This lowers the coinsurance / copayment amount you must pay for your Part D drug. Please note, if we grant your request to cover a Part D drug that is not on our formulary, you cannot ask for an exception on the copayment or coinsurance amount we require you to pay for the Part D drug.
- What is an exception?
Generally, we will only approve your request for an exception if the alternative Part D drugs included on the Plan formulary or the Part D drug in the preferred tier would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
Your doctor must submit a statement supporting your exception request. In order to help us make a decision more quickly, the supporting medical information from your doctor should be sent to us with the exception request.
If we approve your exception request, our approval is valid for the remainder of the Plan year, so long as your doctor continues to prescribe the Part D drug for you and it continues to be safe for treating your condition. If we deny your exception request, you may appeal our decision.
Note: If we approve your exception request for a Part D non-formulary drug, you cannot request an exception to the co-payment or coinsurance amount we require you to pay for the drug.
You may contact us to ask for any of these requests at:
Part D Coverage Determinations (about your Part D Prescription Drugs)
- PHONE 1-877-883-9577. Calls to this number are free.
- TTY/TDD 1-800-421-1220. This number requires special telephone equipment. Calls to this number are free.
- FAX 1-800-956-2397
- WRITE Pharmacy Management Department, P.O. Box 40320, Rochester, NY 14604
- Send a Coverage Determination Request (via Secure Eform) to begin the determination process
For information on the status of your exception request call Customer Service toll-free at 1-877-883-9577 (TTY/TDD 1-800-421-1220) 8 a.m. to 8 p.m. Monday - Friday. From Oct. 1 to Feb. 14, representatives also are available weekends from 8 a.m. to 8 p.m.
- For members/providers: Medicare Prescription Drug Determination Request Form
Your doctor may if they choose, request prior authorization for you using these forms.
- Follow this link to Learn about Medication Therapy Management.
If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan.
Select your plan to learn more:
Do you believe you have qualified for extra help and that you are paying an incorrect copayment amount?
If you believe you are paying an incorrect copayment amount when you get your prescription at the pharmacy, we can help you confirm your eligibility. We follow Medicare's Best Available Evidence Policy and if you have the appropriate documentation, we can help you sort out your eligibility issues. Call Customer Service toll-free at 1-877-883-9577 (TTY/TDD 1-800-421-1220) 8 a.m. to 8 p.m. Monday - Friday. From Oct. 1 to Feb. 14, representatives also are available weekends from 8 a.m. to 8 p.m.
What is Best Available Evidence?
Medicare's Best Available Evidence Policy is used to determine eligibility for extra help with prescription drug costs when information is not readily available to us through other standard sources. This policy allows a member, member's pharmacist, advocate, representative, family member or other individual acting on behalf of the member to submit certain documentation that we will use to update a member's eligibility when appropriate
Examples of Acceptable Documentation
Permissible documents are as follows:
- A copy of the beneficiary’s Medicaid card that includes the beneficiary’s name and an eligibility date during a month after June of the previous calendar year;
- A copy of a state document that confirms active Medicaid status during a month after June of the previous calendar year;
- A print out from the State electronic enrollment file showing Medicaid status during a month after June of the previous calendar year;
- A screen print from the State’s Medicaid systems showing Medicaid status during a month after June of the previous calendar year;
- Other documentation provided by the State showing Medicaid status during a month after June of the previous calendar year;
- A letter from SSA showing that the individual receives SSI; or,
- An Application Filed by Deemed Eligible confirming that the beneficiary is “…automatically eligible for extra help…” SSA publication HI 03094.605
If You are Dual Eligible
To establish that you are a full benefit dual eligible individual, institutionalized and qualify for a zero cost-sharing level, we will accept any one of the following forms of proof:
- A remittance from the facility showing Medicaid payment for a full calendar month for that individual during a month after June of the previous calendar year;
- A copy of a state document that confirms Medicaid payment on behalf of the individual to the facility for a full calendar month after June of the previous calendar year;
- A screen print from the State’s Medicaid systems showing that individual’s institutional status based on at least a full calendar month stay for Medicaid payment purposes during a month after June of the previous calendar year.
- Effective as of a date specified by the Secretary, but no earlier than January 1, 2012, a copy of:
- A State-issued Notice of Action, Notice of Determination, or Notice of Enrollment that includes the beneficiary’s name and home and community based services (HCBS) eligibility date during a month after June of the previous calendar year;
- A State-approved HCBS Service Plan that includes the beneficiary’s name and effective date beginning during a month after June of the previous calendar year;
- A State-issued prior authorization approval letter for HCBS that includes the beneficiary’s name and effective date beginning during a month after June of the previous calendar year;
- Other documentation provided by the State showing HCBS eligibility status during a month after June of the previous calendar year; or,
- A state-issued document, such as a remittance advice, confirming payment for HCBS, including the beneficiary’s name and the dates of HCBS.
For additional assistance on where to send your documents, please call Customer Service toll-free at 1-877-883-9577 (TTY/TDD 1-800-421-1220) 8 a.m. to 8 p.m. Monday - Friday. From Oct. 1 to Feb. 14, representatives also are available weekends from 8 a.m. to 8 p.m.
Follow this link to View Medicare's Best Available Evidence Policy. You will be taken to the Centers for Medicare and Medicaid Services (CMS) Website.
As a new member in our Plan you may be taking drugs that aren't on our formulary or that are subject to certain restrictions, such as prior authorization or step therapy. Current members may also be affected by changes in our formulary from one year to the next. The plan will provide a temporary supply of the non-formulary drug if you need a refill for the drug during the first 90 days of your new membership in our Plan. If you are a current member affected by a formulary change from one year to the next, we will provide a temporary supply of the non-formulary drug if you need a refill for the drug during the first 90 days of the new plan year.
When you go to a network pharmacy and we provide a temporary supply of a drug that isn't on our formulary, or that has coverage restrictions or limits (but is otherwise considered a "Part D drug"), we will cover a one-time 30-day supply (unless the prescription is written for fewer days). We will provide you and your provider with a written notice after we cover your temporary supply. This notice will explain the steps you can take to request an exception and how to work with your doctor to decide if you should switch to an appropriate drug that we cover.
If you are a new member and a resident of a long-term-care facility (like a nursing home), we will cover a temporary 31-day transition supply (unless the prescription is written for fewer days). If necessary, we will cover more than one refill of these drugs during the first 90 days you are a new member enrolled in our Plan. If you are a long-term care facility resident and have been enrolled in our Plan for more than 90 days and need a drug that isn't on our formulary or is subject to other restrictions, such as step therapy or dosage limits, we will cover a temporary 31-day emergency supply of that drug (unless the prescription is for fewer days) while you pursue a formulary exception.
Upon receiving your written notice about your medication from the plan, we recommend that you talk to your doctor and decide if you should switch to a different drug that we cover or request a formulary exception to get coverage for the drug. See Section 9 of the Evidence of Coverage under "What is an exception?" to learn more about how to request an exception. Please contact our Pharmacy Help Desk for any additional questions about our transition policy.