Formulary Management

The drug list, also called a formulary, includes both brand and generic drugs. It will tell you whether any restrictions or limitations to coverage exist such as:

  • Prior authorization
  • Step therapy
  • Quantity limits

Drugs that are subject to these rules are clearly labeled in the drug list and on our drug pricing tool.

We may periodically make certain changes within our formulary, such as:

  • Adding or removing a drug from the drug list
  • Moving a drug to higher or lower tier
  • Adding or removing coverage restrictions
  • Replacing a brand name drug with a generic
  • Or if the U.S. Food and Drug Administration finds that a drug on the formulary is unsafe and the manufacturer removes it from the market, we will update our formulary accordingly.

If you happen to be taking any of the drugs that fall within these changes, we will notify you of these changes.

We may have monthly changes to our formulary. This means that certain drugs may no longer be covered. Please check the current formulary for list of covered drugs and talk to your doctor to see if an alternative covered drug is appropriate or to ask us for an exception.

Formulary

Our Covered Drugs.

We’ve curated a formulary (a list of covered drugs) with a team of healthcare providers that covers many medical conditions at an affordable cost.

Access our easy-to-use prescription drug look up tool.

Download our formulary.

Prior Authorization Criteria

A prior authorization may be required for certain prescription drugs.

Step Therapy Criteria

You may be required to try a certain drug to treat your medical condition before another drug is covered for that condition.

formulary
formulary
  • Important Message About What You Pay for Vaccines – Our plan covers most Part D vaccines at no cost to you, even if you haven’t paid your deductible. Call Pharmacy Member Services for more information.
  • Important Message About What You Pay for Insulin – You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on, even if you haven’t paid your deductible
Page Last Updated On: October 19, 2022
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Tom Cunniffe

Director of Operations 

Tom Cunniffe comes to eternalHealth with over 20 years of healthcare operations’ experience, having held leadership positions in Call Center, Enrollment, Credentialing, UAT and Reimbursement teams. Tom has worked with Medicaid, Commercial and Medicare lines of business and has consistently built teams who are metrics driven with proven successful outcomes. Making sure our business strives for an efficient, best-in-class customer experience is at the center of Tom’s philosophy.

Tom has a bachelor’s degree from Fordham University and a master’s in business administration from University of Massachusetts at Amherst.

Tom Lawless

Chief Financial Officer

Tom Lawless has spent the past 20+ years building, sustaining, and growing new healthcare-related programs that balance fiscal responsibility & prudence with creativity & innovation, focusing on models of care that are novel, person-centered, and improve the social welfare of those who are served. He is very excited to continue doing so in his role as the Chief Financial Officer of eternalHealth.

Tom comes to eternalHealth from a not-for-profit, member-centric, health insurance cooperative. He helped the company continuously strive toward its dual goals of thriving financially, while keeping members at the very epicenter of its mission and service model. While there, Tom also spearheaded the creation of a brand new private, charitable foundation, which will be meaningfully giving back to those in need in the surrounding communities for years to come. Previously, Tom worked in the finance department of a successful hospice that provided high-quality care to persons experiencing their unique and poignant end-of-life journeys, assuring that the appropriate financing was always available. Tom’s career began as a civil servant in the Wisconsin Medicaid program, where he helped to create a program that expanded the institutional entitlement to care into home and community-based settings. Starting with only a blueprint in hand, the program now serves more than 57,000 frail elders and disabled adults and is considered a national model. Growing into a senior leadership role, Tom was a key architect of an innovative financing model, through which the public and private sectors successfully collaborated to better the lives of persons in great need.

Tom holds undergraduate and graduate degrees from the University of Chicago, with additional graduate work in economics completed at the University Wisconsin-Madison.

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