The cost of prescription drugs has increased dramatically over the past decade and become a tremendous responsibility for the Tulalip Tribe,
especially when there has been no restriction or limit on prescription coverage. This prescription coverage has been funded through the Tulalip
Prescription Benefit Program, which is a "payer of last resort" program. In an effort to ensure long-term sustainability of the prescription benefit
and to provide the best and safest health care for our members, the Board approved a resolution in March of 2015 to create the Tulalip Prescription Formulary
and Coverage Guidelines.
Q What is a "payer of last resort" program?
The Tulalip Prescription Benefit is required to be the payer of last resort. This means it will cover any remaining prescription cost when all available
primary coverage sources are billed first. In other words, members must make reasonable effort to enroll and maintain primary coverage to receive Tulalip
Q What is a formulary?
A formulary is a preferred list of medications intended to help guide prescribing decisions, developed using evidence based guidelines and best practice
recommendations from multiple groups.
Q Why is a formulary useful?
Formulary drugs were carefully selected by clinic providers and pharmacists. These drugs are chosen based on efficacy, safety, and cost-effectiveness.
Q What are the limitations?
Members are required to maintain active primary insurance or to have a pending primary insurance application before their prescriptions will be covered
by the Tulalip Prescription Plan. In addition, your prescriptions must meet any restriction or limitation imposed by your primary insurance. Prescriptions
may be dispensed up to the quantities allowed by member’s primary insurance. There will also be a limit to the frequency and total cost of covered replacement
for lost or stolen prescriptions.
Q What if my current medication is not covered?
You or your pharmacy will contact your provider to request a switch to an equivalent product that is covered by the formulary. If your provider decides none of
the formulary equivalent products are suitable for you, he/she can submit a prior authorization request to the Tulalip Pharmacy & Therapeutics Committee.
Q If I have been on a medication for years, and now it is not going to be covered, will I need to change medications?
If your provider decides it’s in your best interest to continue your current medications, he/she can submit a prior authorization request to the Tulalip Pharmacy
& Therapeutics Committee.
Q What is prior authorization request?
A prior authorization request is how your doctor may ask for a non-formulary medication to be covered by the Tulalip Benefit. This request will be reviewed by a
group of pharmacists and providers who will decide if the request is medically justified. If the request is not approved, your doctor may choose a different medication
that is covered by the formulary. The prior authorization process usually takes 2–7 days, depending how quickly your provider submit the required documentations.
Q What is step therapy?
There are first-step medications that are high quality and good values. These medications are preferred choices to try first. If a first-step medication doesn't
work well for you or doesn't agree with you, there are other medications that can be tried next. Often, the first-step medications are generics that have been proven
safe and effective for many patients over many years.
Q Do we have time to make all these changes?
Beginning May 2015, detailed information about the new formulary and prescription coverage guidelines will be available at the Tulalip Health Clinic, Tulalip Family
Services, Tulalip Clinical Pharmacy, and on this Tulalip Clinical Pharmacy website. In addition, the Tulalip Clinical Pharmacy staff will prepare personalized notification
letters to affected members. These personalized notification letters will help members understand how they might be affected and what we can do to resolve coverage issues.
Q Is this going to affect my prescription obtained outside the Tulalip Health System?
Yes. Tulalip Prescription Coverage covers only prescriptions written by outside providers if the prescription is in the Tulalip Prescription Formulary and if they are first
billed through your primary insurance. Some drugs might be restricted to outside providers who meet certain criteria. For example, Buprenorphine (Subutex) and
Buprenorphine/Naloxone (Suboxone) prescriptions will only be covered if they are prescribed by Tulalip Health System providers or by outside SAMHSA-certified providers who
provide DBHR-approved consultations.
*SAMSHA= Substance Abuse and Mental Health Services Administration, DBHR=Division of Behavioral Health and Recovery
Q What if I have questions?
Please feel free to contact the Tulalip Clinical Pharmacy staff if you have any question regarding the new Formulary and Coverage Guidelines.
You can reach us by phone
(360-716-2660) or by email (firstname.lastname@example.org).