Prescription Coverage Information

Prescription Coverage

2025 Plans

WHA is transitioning its prescription drug benefits to a Premium Formulary and Essential Health Benefits Formulary effective January 1, 2025. This is a proactive move for WHA to bend the trend of managing prescription costs more effectively for our members, while also maintaining accessibility to necessary medications. WHA is a health plan built on access and affordability. With this move, we’ve developed the right balance in our Pharmacy Benefits with OptumRx, enabling us to maintain options selected for clinical effectiveness, while still providing access to affordable medications and lower-cost alternatives. This also allows WHA to remain aligned with industry best practices and trends. Learn more by visiting the 2025 Formulary resources page here.

2024 Plans

Your copayment summary for plans with an annual renewal date in 2024 will help you determine whether your prescription coverage uses the three or four-tier plan. It is important to note that prescription coverage may be subject to pharmaceutical management (for example, prior authorization). Additionally, there are a small number of drugs, regardless of tier, that may require prior authorization to ensure appropriate use.

Three-tier Plan (2024)	Four-tier Plan (2024)
Preferred generic medications listed on the Preferred Drug List are covered at the lowest tier copayment level Preferred brand name medications listed on the Preferred Drug List are provided at the second-tier copayment level Non-preferred drugs listed on the Preferred Drug List are covered at the third-tier copayment level Note: Unique cost shares apply for self-injectable medications, and medications for the treatment of infertility (if covered) and erectile dysfunction (see copayment summary)	Preferred generic medications and certain preferred brand-name medications listed on the Preferred Drug List are covered at the lowest tier copayment level Preferred brand name medications and certain non-preferred generic medications listed on the Preferred Drug List are provided at the second tier copayment level Non-preferred drugs listed on the Preferred Drug List are covered at the third tier copayment level Specialty medications, drugs that require special training or clinical monitoring, and drugs that cost more than $600 per month are covered at the fourth tier copayment level Note: Unique cost shares apply for self-injectable medications, and medications for the treatment of infertility (if covered) and erectile dysfunction (see copayment summary)

Three-tier Plan (2024)

Four-tier Plan (2024)

Preferred generic medications listed on the Preferred Drug List are covered at the lowest tier copayment level
Preferred brand name medications listed on the Preferred Drug List are provided at the second-tier copayment level
Non-preferred drugs listed on the Preferred Drug List are covered at the third-tier copayment level

Note: Unique cost shares apply for self-injectable medications, and medications for the treatment of infertility (if covered) and erectile dysfunction (see copayment summary)

Preferred generic medications and certain preferred brand-name medications listed on the Preferred Drug List are covered at the lowest tier copayment level
Preferred brand name medications and certain non-preferred generic medications listed on the Preferred Drug List are provided at the second tier copayment level
Non-preferred drugs listed on the Preferred Drug List are covered at the third tier copayment level
Specialty medications, drugs that require special training or clinical monitoring, and drugs that cost more than $600 per month are covered at the fourth tier copayment level

Note: Unique cost shares apply for self-injectable medications, and medications for the treatment of infertility (if covered) and erectile dysfunction (see copayment summary)

For group plans with effective dates in 2024, please use the drug lists below as a reference to review 2024 coverage:

Beginning January 1, 2025, certain medications will not be included as part of your prescription drug formulary. Drugs not listed on the formulary are called non-formulary or excluded drugs. Call the customer service number on your WHA ID card to initiate an inquiry for coverage of a non-formulary medication from your provider or fill out secure online form here for WHA to send an inquiry to your provider on your behalf.

Prescription Costs

For plans with prescription coverage, you will pay the lesser of the retail price, or cost sharing as described below, for any prescription, retail or mail order. Refer to your copayment summary for additional details.

Copay Plans	Deductible Plans
Use WHA's prescription drug search to find the medication listed on the Preferred Drug List Identify the medication's tier Refer to your copayment summary for the copayment that is associated with that tier	Refer to your copayment summary to determine if prescriptions are subject to a deductible on your plan Use OptumRx's pricing tool to price a prescription medication under the deductible. Once your deductible has been met, refer to the instructions for copay plans to determine your share of costs

On January 1, 2025, the cost or coverage of your current medication may change. If you are currently taking appropriately prescribed medication and your health care provider continues to prescribe this medication for you, you may remain on this medication, in accordance with state law. However, the medication may be subject to placement on a different tier resulting in a change in cost sharing. Speak to your provider regarding medication options under the new formulary or visit our pharmacy website for more information.

Prescription Creditable Coverage

Each year, WHA determines which of its offered prescription drug plans are "creditable." This term is applied to a plan if it is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays. If your WHA plan is creditable, then you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

Proof of creditable status is available by signing up and logging in to mywha.org; once in your MyWHA account, look under MyDocuments/My Benefits. In the event that your plan is not considered creditable, there will be a specific non-creditable notification available to provide information specific to you and your current coverage.

Drug Recalls and Withdrawals

Western Health Advantage is committed to ensuring our members and providers have access to FDA-issued drug recall and withdrawal information. For recall question, please contact WHA Member Services toll-free at 888.563.2250.

For a current list of Class 1 drug recalls and withdrawals, please see our Drug Recalls and Withdrawals webpage.

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Prescription Coverage Information