Our goal is to optimize patient outcomes through the use of medications that have established efficacy and safety data while also providing the greatest value.
Pharmacy Changes and Notifications Pharmaceutical Management, Processes, and Policies Pharmaceutical Management Procedures The prescription drug list (PDL) includes a list of preferred medications, along with the edits listed below that will determine if an authorization for medical necessity/exception process needs to be followed. If an authorization is required, please follow the steps below to complete a medication authorization form, and send the completed form to PHP for review:
Keys To Symbols 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.
Generic Medication Policy
Members will have the lowest cost share with a Tier 1 medication, so consider prescribing a generic, Tier 1 medication when appropriate.
When a brand-name medication becomes available as a generic, that brand-name product may have a higher cost share for the member.
The pharmacist may substitute the name brand for a lower cost generic equivalent unless the physician specifies that the medication must be dispensed as written (DAW).
Therapeutic Interchange
PHP may call or fax the office indicating that criteria was not met for the requested medication, however the member would meet criteria for a different medication(s) with similar therapeutic objectives.
PHP would ask the provider if they would be willing to switch to the preferred medication.
If the provider agrees, PHP will withdraw the original case with a note stating that the provider is willing to switch to a preferred medication.
For preferred medication that requires authorization, a new case will be started for the preferred medication.
An approval letter for the preferred medication that the provider agreed to change will be sent to the member and the provider.
Step Therapy Policy All drugs with a step therapy are labeled with ST in the prescription drug list. All requirements related to a step therapy for a certain drug are included in the step therapy document listed below. Step Therapy Criteria
Prior Authorization Process Certain drugs on the formulary require prior authorization. These drugs will not be approved for payment until the conditions for approval of the drug are met and the authorization processed by PHP. Please access prior authorization criteria
Please note: Medications requiring prior authorization, as well as criteria for use, are subject to change. For the most up-to-date information on coverage and cost of a medication, call Customer Service at 800.832.9186
Medication Prior Authorization Form
Exception Process Medications that are not listed in the prescription drug list (PDL) are excluded from coverage, or medications that are excluded based upon the members' benefit design must be reviewed with the exception process. Online Medication Exception Process Form
Prescription Drug Formularies
Prescription Drug Formularies
Medication Notification Table Medication Authorization Form CVS Specialty Pharmacy Pharmacy Specialty, Infusion Referral, and Mail-Order Forms Preventive Medication Flyer Drug Recalls Real-Time Benefits Provider Prescribing Tool Medical and Drug Policies Archived Pharmacy Changes and Notifications
Effective Date:
Description of updates:
Oct. 1, 2022 100122 Site of Care Flyer July 1, 2022 070122 Formulary Changes July 1, 2021 Migraine Medications & ProAir Changes Jan. 1, 2022 010122 Formulary Changes Jan. 1, 2021 010121 Formulary Changes
Symbicort
Dec. 5, 2020 Pharmacy Vaccine Coverage Oct. 1, 2020 Albuterol HFA changes Site of care update Changes to select brand named drugs April 1, 2020 Trouble shooting pharmacy claims processing for: Adderall XR, Advair Discuss, Concerta April 1, 2020 Biosimilars preferred for infliximab Jan. 1, 2020 Oncology Biosimilars
July 1, 2019
Site of Care Policy Daily limits to diabetic supplies Step Therapy requirements for select diabetes drugs
Jan. 1, 2019
Formulary Exclusions Formulary Changes and Additions
Oct. 1, 2018
Expanded Vaccine coverage at pharmacies
Jan. 1, 2018
Statins available at $0 copay
This page last updated Dec. 14, 2023.