Prescription Drugs

It includes both brand name and generic drugs. Our pharmacy benefits manager OptumRx creates the list of covered drugs with guidance from the doctors and pharmacists from their Pharmacy and Therapeutics Committee who review clinical evidence about the safety and effectiveness of covered prescription drugs in our formulary. You and your doctor can use the formulary to help you choose the most cost-effective covered prescription drugs.

Within the formulary, medications are placed into cost levels known as tiers.

• • Tier 1 – $ Generic drugs often have the lowest out-of-pocket cost
  • Tier 2 – $$ Preferred drugs generally have a lower out-of-pocket cost than non-preferred brand name drugs.
  • Tier 3 – $$$ Non-preferred brand name drugs
  • Tier 4 – $$$$ Specialty drugs
  • Tier CM – Chemotherapy

If you see letters next to the drug, take note. These letters indicate the drug has coverage requirements or limits. For example, PA means the prescription requires prior authorization. Your doctor needs to submit a drug authorization request on the OptumRx website. Written PA approval needs to be received before the drug will be covered by your plan. Other letters are ST for Step Therapy and QL for quantity limits. Learn more about the requirements for drug coverage in the first pages of our formulary.

Preventive Drug List – Use the buttons below to view the preventive care medications and products that are covered at 100% with $0 cost share

Pharmacy Network – CGHC covers medications at network pharmacies only. Use the buttons below to search for network pharmacies by coverage year.

Access to the  formulary does not guarantee any coverage. It only shows the full list of medications that are available through CGHC’s Prescription Drug Formulary. For complete details on the benefits, limitations, and exclusions of your policy, please read the Certificate of Coverage available on our website or in My Health Portal. Some medications listed on the formulary may not be covered under your specific benefit. Where differences are noted, the Certificate of Coverage and Schedule of Benefits will govern. We reserve the right to add or remove prescription drugs from the formulary as needed. If you have questions regarding your coverage, please call Member Services at 877.514.2442.

Visit OptumRx Website 

This is where you can:

• Locate pharmacies in your area by zip code
• Send medications directly to your home
• Determine the availability of generic substitutes
• Search for drugs and compare pricing options
• Manage your medications and orders using any device
• Set reminders so you take your medications on time
• Get answers to commonly asked questions
• Submit your request for reimbursement for covered medications to OptumRx
  • By mail: Use the OptumRx Prescription Reimbursement Request form (PDF).
  • Online: Use the electronic Prescription Reimbursement Request form on the OptumRx website
• Receive guidance about your pharmacy benefits, such as how to:
  • Determine your financial responsibility for a drug
  • Initiate the exceptions process
  • Handle unexpired mail-order prescription