PHC California uses a formulary (list of covered drugs). The drugs that the plan covers are listed in the Comprehensive Formulary (effective January 1, 2020).
A formulary is a list of covered drugs selected by PHC California in consultation with a team of health care providers and approved by the California Department of Health Care Services. The formulary represents the prescription therapies believed to be a necessary part of a quality treatment program. PHC California will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a PHC California network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review the Member Handbook (effective January 1, 2020).
Generally, if you are taking a drug on our formulary that was covered, we will not discontinue or reduce coverage of the drug except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available as long as it is medically necessary and no alternative drug is available.
If we remove drugs from our formulary, add prior authorization, quantity limits, or step therapy restrictions to a drug, we will tell affected members of the change. We will do this at least 30 days before the change becomes effective. Members who are affected by the change may fill their prescriptions of the drug that was changed up to 90 days after the change effective date.
If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary. We will also tell members who take the drug.
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
- Age: Some drugs on our formulary are not appropriate for and may pose a risk to people of certain ages.
- Prior Authorization: PHC California requires your physician to get prior authorization for certain drugs. This means that you will need to get approval from PHC California before you fill your prescriptions. If you don’t get approval, the plan may not cover the drug.
- Quantity Limits: For certain drugs, PHC California limits the amount of the drug that it will cover. For example, PHC California provides 10 patches per 30 days per prescription of Fentanyl.
- Step Therapy: For certain drugs, PHC California will only cover these drugs after you first try another drug to treat your condition. A drug with a “step therapy” restriction may only be covered if the other drug does not work for you.
You can ask PHC California to make an exception to these restrictions or limits. See below for information about how to request an exception.
If Your Drug Is Not on the Formulary
If your drug is not included in the formulary, you should first contact Pharmacy Customer Service and ask if your drug is covered. If you learn that PHC California does not cover your drug, you have two options:
- You can ask Pharmacy Customer Service for a list of similar drugs that are covered by PHC California. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by the plan.
- You can ask PHC California’s Pharmacy Customer Service to make an exception and cover your drug. See below for information about how to request an exception.
Requesting an Exception to the Formulary
You can ask PHC California’s Pharmacy Customer Service to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.
- You can ask us to cover your drug even if it is not on our formulary.
- You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, PHC California limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
Generally, PHC California will only approve your request for an exception if the alternative drugs included on the plan’s formulary, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
You should contact Pharmacy Customer Service to ask us for an initial coverage decision for a formulary or utilization restriction exception. When you are requesting a formulary or utilization restriction exception, you should submit a statement from your physician supporting your request. We must make our decision within 24 hours or one (1) business day of getting your prescribing physician’s supporting statement.
Prescription Drug Transition Policy
As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.
For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs.
The benefit information provided is a brief summary, not a complete description of benefits. Limitations and restrictions apply. Benefits, formulary, and/or pharmacy network may change.
DHCS 030716 PHC Form 1.0