Drug Formulary

Why is a formulary drug getting rejected?

The following is a list of common reasons a prescription may not process at the pharmacy.

• A limited number of formulary drugs must complete the prior authorization request form before being considered a covered benefit.

• The pharmacy may be submitting the claim under the wrong family member. For example, a prescription for an oral contraceptive will only process if the family member is female.

• Some drugs, like migraine medications, are not taken every day. So, the amount you can get per new prescription or refill is limited to what would be typically needed for that condition. If the pharmacy is submitting a quantity larger than what is allowed, the prescription will not process.

• Retail pharmacies are only able to dispense up to a continuous 30-day supply of medication. If your pharmacy is trying to dispense greater than this amount, the prescription will not process.

To answer your specific questions, please contact Member Services at (920) 490-6900, option #1, or toll-free at 1-888-711-1444, option #1.