Restrictions to the Formulary

For certain prescription medicines, Today's Options^® PPO plans have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these medicines in the most effective way. A team of doctors and pharmacists developed these requirements and limits for Today’s Options PPO to help us to provide quality care to our members.

Examples of utilization management tools include:

• Prior Authorization: Today’s Options PPO requires you to get prior authorization for certain medicines. This means that you will need to get approval from Today’s Options PPO before you fill your prescription. If you don’t get approval, Today’s Options PPO may not cover the medicines.
• Quantity Limit: For certain medicines, Today’s Options PPO limits the amount of the medicine that we will cover per prescription or for a defined period of time. For example, Today’s Options PPO will provide up to 10 capsules per prescription of TAMIFLU^®.
• Step Therapy: In some cases, Today’s Options PPO requires you to first try one medicine to treat your medical condition before we will cover another medicine for that condition. For example, if Medicine A and Medicine B both treat your medical condition, Today’s Options PPO may require your doctor to prescribe Medicine A first. If Medicine A does not work for you, only then will Today’s Options PPO cover Medicine B.
• Generic Substitution: When there is a generic version of a brand-name drug available, Today’s Options PPO network pharmacies will typically give you the equivalent generic version to save you expense unless your doctor has told us that you must take the brand-name drug.
• Therapeutic Substitution: When there is a therapeutic alternative to treat your condition, your pharmacist or Today’s Options PPO Plan may contact your doctor to see if the alternative medicine is appropriate for you. Only your doctor can authorize this change.

Learning if your drug has restrictions

You can find out if your drug is subject to these additional requirements or limits by using the Drug Search tool. If your medicine does have these additional restrictions or limits, you can ask Today’s Options PPO to make an exception to our coverage rules.