Pharmacy Information for Members - Physicians Health Plan

Prescription drug benefits come with many choices. The following information is meant to help you understand those choices and ask your doctor or pharmacist the right questions regarding medications for you and your family.

Understanding Your Prescription Drug Benefits

Physicians Health Plan works to provide the highest quality of healthcare coverage possible in the most cost-effective way. In support of this philosophy, PHP offers a variety of prescription drug benefit packages to its employer groups.

If your group insurance plan with PHP includes a pharmacy benefit, your employer may offer a three, four, or six tier drug benefit programs. Each drug benefit program works with the prescription drug list (PDL). Understanding how the PDL and different tier benefit programs work will help you make the most of your pharmacy benefit.

Save more with CVS! It's easy and convenient to use Caremark.com or the CVS Mobile App to manage your prescription benefits. Use the mobile app to scan the barcode on your Rx label, manage delivery of your prescription drugs by mail (Mail-order form), auto refill, find a pharmacy, and search for lower-cost Rx alternatives. For more information about specialty medications that can be provided by CVS Specialty Pharmacy, please use the following CVS Specialty Pharmacy

Prescription drug benefit programs are designed to provide you with a comprehensive selection of prescription drugs. Together with your doctor, you may refer to these lists to consider your choices and select the appropriate medication to meet your needs. Keep in mind that your certificate of coverage (COC) or summary plan description (SPD) defines your actual benefit coverage and may exclude coverage for certain drugs listed in the PDL.

Looking for health plan records, active claims, deductible accumulators, and more? Select MyPHP.

Looking for a library of basic benefit information? Select Member Reference Desk. There you will find downloadable benefit summaries, the PHP handbook, certificates of coverage, advance directives, privacy statements, pharmacy mail order forms, and prescription drug lists.

What is a Prescription Drug List (PDL)?

The PDL contains generic and brand-name prescription medications that can be used for conditions treated outside of a hospital. The U.S. Food and Drug Administration has approved all drugs on the list. A team of doctors and pharmacists meets regularly to review and update the list.

PDLs are chosen by your employer for your benefit plan. Pharmacy benefits are managed by CVS/Caremark. You can verify the drug coverage you have by contacting PHP Customer Service at 517.364.8500 or 800.832.9186, or by visiting CVS/Caremark. If you are a first-time user of CVS/Caremark, you will need to register with your PHP subscriber number.

Providers can prescribe any drug from the PDL that is deemed medically appropriate for our members. To give patients access to non-PDL medications, providers can request prior approval in writing to PHP. You may initiate the prior approval request via email or phone, but pertinent medical information required to process the request must be obtained by PHP from your physician’s office. The prior approval criteria were developed with input from physicians and pharmacists as well as from current medical literature. You should instruct your healthcare provider’s office to complete the prior approval form and fax it to our on-site Pharmacy Department at 517.364.8413. You and your provider will be notified of the decision to approve or deny the request. If a request is denied, alternatives may be suggested.

Medications listed on the PDL are covered drug products selected according to safety efficacy and quality standards first and then by cost-effectiveness. The PDL contains more than 800 drugs, representing multiple therapeutic needs. The PDL often requires the use of generic drugs.

2024 Prescription Drug List - 3 & 4 Tier Plan Covered medications for up to 4-tier plans
2024 Prescription Drug List - 6 Tier Plan Covered medications for up to 6-tier plans

Keys To Symbols
Symbols used throughout the PDL have these definitions:

ACA = Affordable Care Act Preventative Medications. These are covered at zero copayment ($0) to the Member.

AR = Age Restriction. Prior notification may be required to be eligible for coverage depending on patient age.

GENDER = Gender Limits. Prior notification may be required to be eligible for coverage depending on Patient Gender.

MB = Medical Benefit. Medication is covered only through the medical benefit.

PA = Prior Authorization required. Approval of this medication is required prior to coverage by PHP.

QL = Quantity limit. How much of a drug you can fill during a specific time period.

SP = Specialty Medication. This medication allows a maximum of a one-month supply per fill.

ST = Step therapy. This medication requires trial of a preferred agent prior to coverage.

If you don’t see your medicine listed in the formulary, you may ask for an exception using the:

Medication Prior Authorization Form

Online requests will be reviewed the next business day. Outreach to your provider may need to be done to process your exception request. You and your provider will be notified of the outcome once completed. Notification will go out within 9 days from the date of request based upon the type and urgency of the request.

Understanding Drug Tier Structure
Three Tier Plans

Tier 1 Preferred generic and selected brand name medications. Lowest copayment.

Tier 2 Preferred brand name traditional and specialty medications. These products generally do not have a generic equivalent.

Tier 3 Non-preferred traditional and specialty medications - higher copay than preferred medications. There may be a similar or equivalent drug in a lower tier on the formulary that may provide the same benefit at a lower cost.

Four Tier Plans

Tier 1 Preferred generic and selected brand name medications. Lowest copayment.

Tier 2 Preferred brand name traditional and specialty medications. These products generally do not have a generic equivalent.

Tier 3 Non-preferred traditional medications - higher copay than preferred medications. There may be a similar or equivalent drug in a lower tier on the formulary that may provide the same benefit at a lower cost. High copayment.

Tier 4 Non-Preferred brand and generic specialty medications. Highest copayment.

Six Tier Plans

Tier 1A Selected adherence generic and selected brand name medications. Lowest copayment.

Tier 1B Generic medications.

Tier 2 Preferred brand name traditional medications. These products generally do not have a generic equivalent.

Tier 3 Non-preferred traditional medications - higher copay than preferred medications. There may be a similar or equivalent drug in a lower tier on the formulary that may provide the same benefit at a lower cost.

Tier 4 Preferred specialty brand name and generic specialty medications.

Tier 5 Non-preferred specialty brand name and generic specialty medications. Highest copay amount. There may be a similar drug on a lower tier on the PDL that may provide the same benefit at a lower cost.

Based on benefit design, “Closed” pharmacy benefit plans would not cover non-preferred medications except under certain processes consistent with applicable law.

Prescription Drug List Changes
Visit Pharmacy Services to access the following information:

Additions, changes, or drugs that are removed from the prescription drug list (PDL).

Pharmaceutical management, process, and policies for the formulary.

The physician authorization and exception process for prescription drug submissions.

You may also contact Customer Service at 800.832.9186 or 517.364.8500 with any questions you may have about your pharmacy benefit.

Prior Authorization Process
Approval may be required before you fill a prescription in order for the prescription cost to be covered. The approval process has many names including exception for medication, medical necessity for medication, precertification, pre-authorization, and prior authorization (PA).

The medication prior authorization process usually starts when a physician orders a prescription to be filled at a pharmacy. When a prescription is received at the pharmacy, the pharmacist is alerted that a prior authorization is needed to process the claim. The pharmacist will notify the physician’s office to start the prior authorization process. The physician will collect the information needed for the submission of prior authorization, and submit the request to the health plan for review.

Reasons prior authorizations are necessary:

To ensure the medication or treatment isn’t being duplicated

To ensure that the medication or the treatment prescribed is medically necessary

To make sure that the medication is beneficial to the patient

To help reduce healthcare costs

To help in curbing overprescribing

Exception Process
Medications that are not listed in the prescription drug list (PDL) are excluded from coverage, or medications that are excluded based upon your benefit design must be reviewed through the exception process.

You may initiate the exception process by using the:

Online Medication Exception Process Form

Online requests will be reviewed the next business day. Outreach to your physician may be required to complete the process of your request. You and your provider will be notified of the outcome. Notification will go out within 9 days from the date of the request based upon the type and urgency of the request..
Drug Recall Information
Please use the links below to find drug recall information:
FDA Drug Recalls
CVS Drug Recalls

Preventive Services
Preventive medications covered under the Affordable Care Act (ACA) can be found on the Preventive Medications List.

Opioid Utilization Management
Physicians Health Plan (PHP) has partnered with CVS Caremark to reduce opioid use. Opioids are often overprescribed for acute pain and not always the best medicine for chronic pain. Michigan State Law requires providers and pharmacists to limit the number of opioids that are prescribed, to reduce the amount of medication within each prescription fill, and to prescribe non-opioid alternatives for pain relief when possible. Please reference the CVS Opioid Flyer for more information.

Non-Opioid Directive
The Non-Opioid Directive states that non-opioid medications will be used when pain management is needed unless an opioid is deemed necessary for medical treatment by the provider. This directive can be reversed at any time.

Members who would like to use non-opioid pain management medications can fill out the Non-Opioid Directive form and give the form to their primary care provider (PCP) as a part of their medical record. Parents, guardians, and patient advocates may fill out and submit this form to the PCP on behalf of those in their legal care.

For more information, and to view or download the MDHHS-5793 Nonopioid Directive form, visit the MDHHS Opioid Resources Find Help guide.

English, Spanish and Arabic language versions of the form can all be found in the Additional Resources section.

Specialty Prescription Drug Services
If you require specialty medications (such as those given in a physician’s office or self-injectables), For Tier-3, Tier-4, and Tier-6 plans please use the following:
CVS/Caremark Specialty Pharmacy

For Sparrow Caregivers specialty medications can be obtained through:
Sparrow Specialty Pharmacy

Find a Pharmacy
If your benefit plan includes pharmacy services through PHP, you have access to a nationwide network of pharmacies for prescription refills. In order to locate a pharmacy in-network, you can use our provider directory or visit Caremark. If you are a first-time user of Caremark, you will need to register with your PHP subscriber number.

Pharmacy Claim Reimbursement Form

CVS Reimbursement Form

Get Your Medication

Site view: at a glance

Tier 1	Preferred generic and selected brand name medications. Lowest copayment.
Tier 2	Preferred brand name traditional and specialty medications. These products generally do not have a generic equivalent.
Tier 3	Non-preferred traditional and specialty medications - higher copay than preferred medications. There may be a similar or equivalent drug in a lower tier on the formulary that may provide the same benefit at a lower cost.

Tier 1A	Selected adherence generic and selected brand name medications. Lowest copayment.
Tier 1B	Generic medications.
Tier 2	Preferred brand name traditional medications. These products generally do not have a generic equivalent.
Tier 3	Non-preferred traditional medications - higher copay than preferred medications. There may be a similar or equivalent drug in a lower tier on the formulary that may provide the same benefit at a lower cost.
Tier 4	Preferred specialty brand name and generic specialty medications.
Tier 5	Non-preferred specialty brand name and generic specialty medications. Highest copay amount. There may be a similar drug on a lower tier on the PDL that may provide the same benefit at a lower cost.