Get Your Medication

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 single-, two-, three- or four tier drug benefit program. 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.

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 defines your actual benefit coverage and may exclude coverage for certain drugs listed in the PDL.

What is a 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. 

  • Prescription Drug List This is the list of covered medications. Please note that if you have a 3-tier plan, all medications listed at the 4th tier would fall under the 3rd tier.

  • Sparrow Employee Prescription Drug List If you are a Sparrow Caregiver (employee) and are in group L0001269, then this prescription drug list is applicable to you

Types of prescription benefits

Outlined below are the current options available to employer groups that purchase a prescription drug benefit from PHP. Several copayment combinations are offered within each of these options. Please call PHP Customer Service at 517.364.8500 or 800.832.9186 if you are unsure of which benefit you have or to check your copayments. Members may also visit Caremark. If you are a first-time user of Caremark/CVS, you will need to register with your PHP subscriber number. 

 Three Tier Plans Four Tier Plans 
Tier 1 
  • Preferred generic and selected brand name medications
  • Lowest copay
  • Preferred generic and selected brand name medications
  • Lowest copay
Tier 2
  •  Preferred brand name medications - these products do not have a generic equivalent
  • Preferred specialty medications are also on tier 2 - specialty drugs are used to treat complex conditions like cancer or multiple sclerosis
  •  Preferred brand name medications - these products do not have a generic equivalent
  • Preferred specialty medications are also on tier 2 - specialty drugs are used to treat complex conditions like cancer or multiple sclerosis

Tier 3

  • Non-preferred traditional and specialty medications - higher copay than preferred medications
  • There may be a similar drug on a lower tier on the PDL that may provide the same benefit at a lower cost
  •  Non-preferred traditional and specialty medications - higher copay than preferred medications
  • There may be a similar drug on a lower tier on the PDL that may provide the same benefit at a lower cost
Tier 4 
  • Non-preferred specialty medications
  • Highest copay amount

Note: If your plan has a “closed” pharmacy benefit (single-tier or two-tier pharmacy benefit) then medications on the non-preferred list are generally not covered except under certain processes consistent with applicable law. 

Drug Recall Information

Please use the links below to find drug recall information:

Vaccine services

If your benefit plan includes pharmacy services through PHP, you have access to a nationwide network of pharmacies for vaccines.  For more information, see the Vaccine Flyer.

Preventive services

Preventive medications covered under the Accountable Care Act (ACA) can be found here: 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. Click on the attached flyer for more information. 

 

Outpatient prescription drug services

If your benefit plan includes pharmacy services through PHP, you have access to a nationwide network of pharmacies for prescription refills. If you require specialty medications (such as those given in a physician’s office or self-injectibles), please use one of the following:
  • CVS/Caremark Specialty Pharmacy
  • Coram HealthCare Corporation

 

Find a pharmacy

In order to locate a pharmacy in-network, visit Caremark. If you are a first-time user of Caremark, you will need to register with your PHP subscriber number.

 

Save more with CVS Caremark! It's easy, convenient and smart 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.