Individual and Family Prestige Plan Formulary

Here are a few tips on how to use this drug list.

  • Find your drug in the Index at the end. The index provides an alphabetical list of all medications and what page they are on.
  • Scroll through the Index to find the page number for your medication. Go to that page to find your medication.
  • The columns on each page list the drug name, drug tier number that the medication is classified as and any restrictions that apply to the medication.
  • Abbreviations are explained on the bottom of each page. The drug tier numbers relate to the amount you'll pay for the drug. Typically, the higher the tier number, the more you'll pay. The amount you will pay for each drug tier will depend on the type of plan you have. You can find these costs in your Summary of Benefits and Coverage document available in your member portal.

View 2024 Formulary

View 2023 Formulary

View Prior Authorization and Step Therapy Criteria