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Clear Care HMO and PPO Medicare Advantage Part D Drug Formulary

This formulary is a list of drugs selected by Group Health Cooperative and Group Health Options, Inc.—and approved by the Centers for Medicare and Medicaid Services (CMS)—that are covered by Group Health's Clear Care prescription drug plans. Based on consultation with a team of health care providers, these prescription therapies are believed to be a necessary part of a quality treatment program.

  • When your 2014 Part D coverage begins, up until you have reached $2,850 in covered Part D drug costs, payment will be based on four different levels of coverage for all drugs listed on our Part D Clear Care formulary. The first level is for preferred generic drugs, the second level is for nonpreferred generic drugs, the third level is for preferred brand name drugs, and the fourth level is for non-preferred brand name drugs.
  • Medicare will no longer cover erectile dysfunction (ED) drugs like Viagra, Cialis, Levitra, and Caverject.

2014 Formularies

Please note: Group Health plans require prior authorization or quantity limits for certain drugs. Here is the prior authorization drug list (PDF), and the quantity limit drug list (PDF) for 2014.

Group Health requires you to first try certain drugs to treat your medical condition before covering another drug for that same condition for certain drugs. See 2014 Step Therapy Requirements. (PDF)

Group Health Clear Care plans may add or remove drugs from the formulary during the year. The formulary on this page is current as of March 1, 2014.

  • Future Formulary Changes: None

Generally, if you are taking a drug that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except when we receive information from the FDA that a drug is no longer safe or effective.
Complete information about these changes is included in the formulary documents above.

Group Health Clear Care plans cover both brand name drugs and generic drugs. Generic drugs have the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.

Also see: Formulary Change Policy (PDF)

If a drug isn't covered If your doctor or pharmacist says that a certain prescription drug is not covered, call Customer Service to ask why the drug was not covered. Here are other steps you can take:

  • Talk to your doctor about alternative drugs that are on the Clear Care Part D formulary.
  • Ask your doctor to adhere to rules about quantity limits and prior authorization.
  • Ask your pharmacist to recommend a prescription change to the doctor. Form: Request for Prescription Information or Change (PDF)
  • Seek a formulary exception from Group Health.

Also see: Exceptions, Appeals, and Grievances

Coverage provided by Group Health Cooperative or Group Health Options, Inc.

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Other Resources

Grievance Policy (PDF)
Transition Policy (PDF)

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We offer both Medicare Advantage HMO plans and Medicare Advantage PPO plans in different areas of Washington state.
Clear Care® HMO service area (PDF)
Clear Care® PPO service area (PDF)