Comprehensive Formulary
Use the links below to access the Senior Health Plan Comprehensive Formularies.
Important Message About What You Pay for Vaccines - Our plan covers most Part D vaccines at no cost to you. Call Customer Services 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.
Preferred blood glucose test strips include products made by Roche and Abbott. Preferred diabetic testing supply products include Accu-Chek Guide, Accu-Chek Aviva Plus, Accu-Chek SmartView, FreeStyle, FreeStyle Lite, and Precision Xtra products.
Preferred CGMs include products made by Dexcom and Abbott. Preferred CGM products include Dexcom G6, Dexcom G7, FreeStyle Libre 2, FreeStyle Libre 2 Plus,FreeStyle Libre 3, and FreeStyle Libre 3 Plus.
Quantity Limits and other coverage requirements may apply. If a preferred CGM or diabetic testing product is not clinically appropriate, a prescriber may request coverage of an alternative product through the applicable exception process.
Although not listed in the formulary, Senior Health Plan will cover the Twiist® or Omnipod® insulin management system under your Medicare Part D prescription drug benefit as a Non-Preferred Brand, Tier 4.
Please contact the Pharmacy Help Desk for additional information at 1-877-293-8628 / 918-594-5211 (local) (TTY users should call 1-800-722-0353), Monday through Friday from 8:00 am to 8:00 pm
Part B Rebatable Drug Coinsurance Adjustment
Effective April 1, 2023, certain Medicare Part B drugs may have a lower coinsurance than what is stated in a member’s benefit documents. Members may pay a lower coinsurance if the price of the drug is rising faster than the rate of inflation. The Centers for Medicare & Medicaid Services (CMS) makes the determination on which Part B drugs qualify for the lower coinsurance and the coinsurance adjustment amount. CMS has the right to review and change this list of drugs up to 4 times a year. The Rebatable Drug Coinsurance Adjustment will occur through an enrollee refund if the mandatory reduction occurs after claims have been processed in 2026.
Part B Insulin Cost Sharing Cap
Starting July 1, 2023, Medicare Advantage plans must cover Part B insulin for use in insulin pumps at the copayment and coinsurance cap of $35 for a one-month supply of insulin.
Extended Day Supply for Platinum and Platinum Plus members on Tier 1 medications (100 days or more)
Enjoy the convenience of extended supplies on select Tier 1 medications (100 days or more) and pay $0 copay.
Formulary Changes and Utilization Management Criteria
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