Pharmacy & Formularies

Individual & Family Health Insurance Formularies

CHRISTUS Health Plan offers pharmacy benefits under our individual and family health insurance plans. These benefits apply to prescription drugs in our formularies.

A formulary is a list of generic and brand name drugs chosen by CHRISTUS Health Plan and a team of doctors as part of a quality treatment plan. These drugs are usually covered as long as the drug is medically necessary, the prescription is filled at a network pharmacy and other rules are followed.

Texas & New Mexico Health Insurance Exchange Formularies

2018 Exchange Formularies

2018 Texas Health Insurance Exchange Formulary (PDF)
2018 New Mexico Health Insurance Exchange Formulary (PDF)

Utilization management is a practice where some medical services and drugs are evaluated for need before they can be used. This means that for certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help members use drugs effectively and keep coverage affordable. Examples of utilization management include:

  • Prior Authorization: We may need you to get approval from us before you fill certain prescriptions. If you don’t get approval, we may not provide coverage for the drug.
  • Quantity Limits: We may limit or only cover a certain amount of a drug per prescription or for a period of time.
  • Step Therapy: In some cases, members may need to try one drug to treat their condition before we will provide coverage for another drug.
  • Generic Substitution: When a generic version of a drug is available, our pharmacies will automatically give members that version unless your doctor has told us that you must take the brand name drug.

You can find out if your drug is subject to these additional requirements or limits by looking in our formulary. If your drug does have additional restrictions or limits, you can ask us to make an exception to our coverage rules. Learn more about requesting an exception in the FAQ section.

During a drug utilization review, we check your prescriptions and look for problems like:

  • Possible medication errors
  • Duplicate drugs that are unnecessary
  • Drugs that are inappropriate because of your age or gender
  • Possible harmful interactions between drugs you are taking
  • Drug allergies or dosage errors

These reviews are especially important if you have multiple doctors who prescribe medications. We conduct reviews each time you fill a prescription and on a regular basis. If we see a problem during our review, we will work with your doctor to correct it.

Check your formulary to see if a drug is covered. If you have questions, please contact us 5 days a week, 8 a.m. to 5 p.m. local time.

MM161 & MM162
Last Updated: 2/23/17