Advantage 4-Tier Prescription Drug List (PDL) - Coverage Criteria
A formulary (PDL) describing covered prescription medications, tiering, and coverage controls for Sierra Health and Life medical plan members whose pharmacy benefit uses the Advantage 4-Tier PDL.
No material clinical or coverage changes in this revision.
Coverage Criteria Overview
Medications may be excluded from coverage when there are covered, lower-cost alternatives or over-the-counter options that provide the same therapeutic effect. The plan evaluates treatments for clinical effectiveness, safety and cost; if an equivalent lower-cost covered product exists (including an OTC alternative) the higher-cost product may be excluded or subject to prior authorization. Members and providers should consult benefit documents or the member website for details on exclusions and covered alternatives.
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