Sibley Memorial Hospital PPO Plan — 2023
EHP strives to provide a variety of pharmacy information and resources for our members, such as information related to the pharmacy formulary, pharmaceutical restrictions or preferences, requesting a benefit exception, step therapy, generic substitution, and other pharmacy management procedures. The pharmacy formulary is updated regularly to include new medications and the latest safety information. Use our Health Resources to find information on a drug, including how to take the medication, possible side effects, and drug interactions.
EHP provides prescription drug benefits for several EHP employer groups. However, these benefits may not be applicable to certain employers. Please consult your Summary Plan Description (SPD) for information on specific plan coverage, limitations, and exclusions. Your HR office will be able to provide you with your SPD.
The Advanced Control Formulary (effective 01/01/2023) is a list of medications selected for coverage under the pharmacy benefit, based on efficacy, safety, cost-effectiveness, and clinical evidence. There are often many drugs available to treat the same condition: either a generic drug, brand-name drug, or both. Some drugs with high costs and no significant clinical benefit over similar preferred drugs are not covered under the pharmacy benefit. The drugs listed in the Advanced Control Formulary have shown to be safe and effective, and they may help you save money on your prescriptions. EHP is committed to helping you get the most effective medications at the best price and keeping access to prescription drugs affordable.
The EHP Advanced Control Formulary is subject to change at any time. The formulary is updated on a regular basis, including when new generic or brand-name medications become available and as discontinued drugs are removed from the marketplace. You can review additions/removals to the Advanced Control Formulary:
See if your medication is subject to Utilization Management edits (prior authorization, quantity limit, or step therapy). Registration is required for first-time use.
Your employer group is covered by the EHP pharmacy benefit which has a three-tier drug benefit. Each tier has a different co-pay or out-of-pocket expense. Members are responsible for a portion of the cost of their medications.
- Tier One: Generic
Generic drugs have the lowest out-of-pocket cost for members and are placed on Tier 1. Generic products are listed in the formulary in lowercase italics.
- Tier Two: Preferred Brand
Preferred brand-name drugs have a significant safety or efficacy advantage compared to similar agents. These agents have an intermediate out-of-pocket cost for members. These products are usually placed on Tier 2 and listed in the formulary in all capitals.
- Tier Three: Non-preferred Brand
Non-preferred brand-name drugs do not have a significant, clinically meaningful advantage in terms of effectiveness, safety, and clinical outcomes compared to similar agents. These drugs have higher out-of-pocket cost for members. In most cases, there will be Tier 1 or Tier 2 alternatives for products found in this tier. Non-preferred brand-name drugs covered under the pharmacy benefit are not displayed in the formulary and may process in Tier 3.
If you or your provider requests a brand name drug for which a generic equivalent is available, you will pay the difference between the brand and generic cost plus your Tier 3 copay.
You can use information in the Advanced Control Formulary (effective 01/01/2023) to help you identify the drugs covered under each therapeutic category. To determine your copay or find a lower-cost generic or preferred brand alternative for a medication, you can check your drug’s cost.
When clinically effective options are available to treat your condition, certain medications may be removed from the list of covered drugs. Your doctor always has the final decision on what medication is right for your condition. Remind your doctor that your benefit plan no longer covers this medication, and you may have to pay the full price. Speak with your doctor about writing a new prescription for a covered medication.
Your doctor can view a list of covered drugs and associated tier status on the Advanced Control Formulary. A list of non-covered drugs and the formulary alternatives (preferred options) are also available in the formulary. If you cannot use a formulary medication, your doctor may submit clinical documentation of medical necessity, including treatment failure of covered drugs. Without a prior authorization for medical necessity you may be required to pay the full cost of the medication.
You can save money on your prescriptions by using generic drugs when possible. EHP encourages use of generic medications. Generic drugs are chemically identical to their branded counterparts. They are made with the same active ingredients and produce the same effects as their brand name equivalents. The Food and Drug Administration (FDA) requires generic drugs to have the same quality, strength, purity, and stability as brand name drugs. Also, the FDA requires that all drugs, including generic drugs, be safe and effective.
When a generic drug is substituted for a brand name drug, you can expect the generic to produce the same clinical effect and safety profile as the brand name drug. Brand name drugs that have generics available may: incur higher copayment (Tier 3), require payment of the difference in price between generic and brand in addition to copayment, or require mandatory generic dispensing.
How can you save?
You can use information in the Advanced Control Formulary (effective 01/01/2023) to help you identify the coverage of the medications you are currently taking and discuss less expensive alternatives with your doctor. You can also determine your copay or find a lower cost alternative for a medication online.
Drug Safety Information
Visit the CVS Caremark website to find the latest drug safety information, including how to take the medication, the possible side effects, and drug interactions.
Certain medications require prior authorization before coverage is approved, to assure medical necessity, clinical appropriateness and/or cost effectiveness. Coverage of these drugs is subject to specific criteria approved by physicians and pharmacists on the Pharmacy and Therapeutics Committee. Established criteria are based on medical literature, physician expert opinion, and FDA approved labeling information. See if your medication requires prior authorization.
How does prior authorization work?
Your physician may request prior authorization electronically by completing an online prior authorization request form. Your physician may also call CVS/caremark and fax the required clinical information to request a prior authorization.
Prior authorization requests are generally processed within specific timelines determined by National Committee for Quality Assurance (NCQA) upon receipt of a completed prior authorization form. Your physician will be notified of the request’s approval or denial by fax and you will be notified by mail.
Certain prescription medications have specific dispensing limitations for quantity and maximum dose. These dispensing limitations are based on generally accepted guidelines, drug label information approved by the FDA, current medical literature, and input from a committee of physicians and pharmacists. The three types of quantity limits include the following:
- Coverage limited to one dose per day for drugs that are approved for once daily dosing
- Coverage limited to specific number of units over a defined time frame
- Coverage limited to approve maximum daily dosage
See if your medication is subject to quantity limits. When medically necessary, your physician may request prior authorization for a quantity greater than the set limit by completing an electronic Prior Authorization request or faxing the required clinical information to CVS/caremark.
Note: Quantity Limit exception requests are generally processed within specific timelines determined by National Committee for Quality Assurance (NCQA) upon receipt of a completed Prior-Authorization form. Your physician will be notified of the request’s approval or denial by fax and you will be notified by mail.
Certain drugs require that you first try a preferred drug to treat your medical condition before we cover the drug your doctor may have initially prescribed. This is called step therapy. See if your medication requires step therapy.
When medically necessary, your physician may request an exception to the step therapy requirement and ask for prior authorization by completing the electronic prior authorization form or faxing the paper form to the required clinical information to CVS/caremark.
Pharmacy Compounded Drugs
To ensure safety and effectiveness of compound drug claims and to manage cost, some compound medications when rejected at the pharmacy, may require prior authorization. In such cases, your provider must provide clinical documentation to support the request and demonstrate that an FDA-approved commercially-available product is not clinically appropriate for you. Your provider should contact CVS/caremark and fax the required clinical information to support the request.
Specialty medications are used to treat complex, long-term conditions. These are medications that may need special storage or have side effects that your health care provider needs to monitor. Some of these medications are covered by your pharmacy benefits and some are covered by your medical benefits.
Specialty medications covered by your pharmacy benefit are available at a local pharmacy. You take these medications on your own. For some of them, your provider may have to ask EHP to approve them. See if your medication requires prior authorization. Your physician may request prior authorization electronically by completing an online prior authorization request form. Your physician may also call CVS/Caremark and fax the required clinical information to request a prior authorization.
Specialty medications covered under medical benefit are either given to you by your provider or taken while your provider is there with you. Some of these medical drugs may require prior authorization and your doctor may ask EHP to approve them. Your doctor can find a list of medical drugs that have this PA requirement by visiting jhhc.com.
Our Pharmacy Network
Our pharmacy network includes over 64,000 pharmacies nationwide. The network includes most chain retailers and independent pharmacies. Search for a participating network pharmacy near you. Registration is required for first time use.
Don’t want to go to the pharmacy to get your prescriptions? Try mail order. This service offers a convenient and cost-effective option for obtaining medications you take on an ongoing basis. You can receive up to a 90 day supply of chronic use medications and have these medications delivered to the location of your choice. Mail Order service is provided by CVS/caremark. You can refill your prescription online (registration required) or use the Mail Order form.