Gateway Health Plan® has a list of drugs for which we pay. This drug list is known as a formulary.  These drugs are reviewed and recommended for the formulary by our Pharmacy and Therapeutics (P&T) Committee and the Department of Public Welfare (DPW).  The drugs are approved for the formulary because they have been proven to be safe and effective.  The P&T Committee consists of doctors and pharmacists who consider safety, efficacy, quality and cost when reviewing a drug for the formulary. This in-depth review helps to provide members with quality, cost effective drugs to treat disease.
Gateway’s formulary can be reviewed online at www.GatewayHealthPlan.com.  You can call our Pharmacy Member Service Department at 1-800-392-1147 if you have questions about the formulary.

What is a Prior Authorization for Drugs?
There are some drugs that Gateway must approve before you can get them at the pharmacy.  For these drugs, clinical standards based on medical studies must be met and approved by the P&T Committee and DPW, or additional information must be provided before coverage (payment) is approved.  You doctor will provide Gateway with reasons this drug was requested to assure the drug is being used appropriately. Once your doctor has provided this information, Gateway will make a decision within 24 hours.  Drugs requiring a prior authorization are marked with a “PA” on the online formulary.  If you have questions regarding medications that require a prior authorization, please call the Pharmacy Member Service Department at 1-800-392-1147.

What is Step Therapy?
In some cases, Gateway may require you try a certain drug to treat your medical condition before we will cover another drug for your condition.  For example, if Drug A and Drug B both treat your medical condition, Gateway may not cover Drug B unless you try Drug A first.  If Drug A does not work for you, Gateway will then cover Drug B.  Drugs requiring step therapy are marked with an “ST” on the online formulary.

Why are there Quantity Limits on drugs?
For certain drugs, Gateway may limit the amount of the drug that we will cover.  Prescriptions in excess of the covered monthly quantity will need to be requested by your physician and will be reviewed by a pharmacist and medical director at Gateway.  Drugs with quantity limits are marked with a “QL” on the online formulary.  Quantity limits are based on the Food and Drug Administration (FDA) recommended dosing and are put in place for your safety.