Pharmacy Information
PAI's preferred pharmacy benefit manager is OptumRx, a pharmacy care services company that creates smarter health care connections to help more than 65 million Americans realize improved care, lower costs, and a better overall experience.
The following drug lists apply to members with PAI’s pharmacy benefit coverage with OptumRx. Contact the Customer Service number on the member ID card if you need assistance.
- Drug Lists
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Lowest Cost Net Formulary - Also referred to as the Preferred Drug List, applies to most of our benefit plans, with just a few exceptions.
Excluded Drug List - Shows drugs that are excluded from coverage, as well as how to request a formulary exception.
Specialty Drug List - Features drugs that are used to treat complex or chronic medical conditions.
$0 Covered Drug List - The Affordable Care Act (ACA) requires most health plans to cover certain drugs at no cost to members.
- Drug Management Programs
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Prior Authorization - Applies to prescription drugs that require prior authorization.
Quantity Management - This program limits the amount we cover for certain drugs. We provide medical necessity exceptions for some of these limits when you request and receive prior authorization for them.
Step Therapy - Step therapy requires members to try cost-effective “First Choice” medications before trying (or “stepping up to”) more expensive “Second Choice” medications. We provide medical necessity exceptions when you request and receive prior authorization for them
- Specialty Medical Medications
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PAI requires prior authorization for some specialty drugs billed under the medical benefit. Also, the medical benefit does not cover certain self-administered specialty drugs.
Medical Drug List - View this list to find out which medical specialty drugs require prior authorization under the Specialty Medical Benefit Management (SMBM) program.
Self-Administered Specialty Drugs - View this list to view self-administered specialty drugs.