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This formulary listing is intended for the use and application to those plans subject to the AultCare Formulary.
This formulary does not apply to those plans not governed by the formulary. Refer to your "AultCare Prescription Drug Program" brochure to see if the formulary applies to your plan. AultCare offers our members an open formulary design (which means that the health plan may cover the costs of drugs that are not on the formulary list). Therefore, tier exceptions are not applicable. For example, a higher tier
(Non Preferred) medication may not be requested at a lower tier (Preferred) co-pay.
If there are additional questions, please call the AultCare Service Center at (800) 344-8858.
If your ID card says Marketplace Formulary, only specific drugs in
each therapeutic class are covered. Medications not listed on our formulary are not covered under the plans. Click the button above:
Non-Forumlary Drug Coverage Determinations, to learn about non-formulary coverage determinations.
Specialty Mail-Order Rx- effective 1/1/2019
Brand Name Medications that now have Generic equivalents available
* All strengths & dosage forms may not be available (Generic name in parenthesis) *
- Actonel 150 mg(Risedronate)
- Protopic Ointment(Tacrolimus ointment)
- Mirapex ER 0.75 mg, 1.5 mg (Pramipexole ER)
- Vivelle-DOT(Estradiol patch)
- Vigamox ophth soln(Moxafloxacin ophth soln)
- Generess FE(Norethindrone/Eth Estradiol/FE)
- Patanase spray(Olopatadine spray)