Pharmacy Services

At a Glance

Welcome to Premier Health Plan Pharmacy Services. Premier Health Plan Pharmacy Services partners with the physician-led network of Premier Health Group providers to meet the medication and cost needs of patients. Our approach focuses on improving patient health through coordinated formulary and Care Advising programs that enhance the member and provider experience.

Premier Health Plan develops a formulary of medications chosen based on clinical effectiveness, safety and value. The formulary is developed by physicians and clinical pharmacists. The formulary’s pricing strategy is designed to achieve the goal of better clinical outcomes at an affordable cost.

The Premier Health Plan formulary includes the following features:

  • Required generics
  • Once-daily dosing initiatives to improve patient compliance
  • Lists of preferred drugs (formulary medications)
  • Prior authorization or step therapy requirements for selected medications
  • Quantity limits (based on FDA guidelines and accepted standards of care)

Contact a Clinical Pharmacist

Premier Health Plan encourages providers to contact the Pharmacy Services Department from Monday – Friday, 8:00 am – 5:00 pm, with comments or questions about a member’s medication history, duplicate medications or compliance. A dedicated clinical pharmacy team is available to provide extra support, including

  • Answering medication-related questions from providers and network pharmacies
  • Developing and conducting prospective and retrospective drug utilization reviews
  • Supporting providers, network pharmacies and members on pharmacy changes
  • Serving as a clinical resource for the provider network
  • Conducting a medication therapy management (MTM) program
  • Providing physician and patient education materials to network practices to support drug selection and use based on the best objective and clinical evidence

    Contact the Pharmacy Services Department at:

    Premier Health Employee Plan (855) 266-0713(855) 266-0713

    Prior Authorization 

    A limited number of medications require authorization before they are provided to members. Authorizations may be needed for the following reasons:

    • Prior authorization or a step therapy requirement as indicated on the formulary
    • Prescriptions that exceed Premier Health Plan quantity limits
    • Non-formulary medications
    • Early refills

    In some cases, clinical documentation is necessary to review these medication requests. All requests will be reviewed promptly, and the decision will be communicated to the physician or member.

    How to Receive Prior Authorization

    To receive authorization for a medication requiring a prior authorization or quantity limits, or a non-formulary medication:

    1. Obtain a prior authorization form
    2. Fax to (855) 862-6518
    3. Call (855) 869-7140(855) 869-7140

    Premier Health Plan will immediately communicate all coverage determinations and prior authorization decisions by fax to the physician’s office once the review process is complete. If a fax number is not available, Premier Health Plan will communicate decisions by phone and will mail a copy of any decision documentation to the provider’s office.

    Physicians should notify patients of all pharmacy prior authorization decisions determined by Premier Health Plan.

    Pharmacy Policies

    Prior Authorization Criteria

    Prior authorizations are set on a specific drug-by-drug basis and require specific criteria for approval based upon FDA and manufacturer guidelines, medical literature, safety concerns and appropriate use. Drugs that require prior authorization may be

    • Newer medications requiring monitoring by Premier Health Plan
    • Medications not used as a standard first option in treating a medical condition
    • Medications with potential side effects that Premier Health Plan would like to monitor to ensure safety

    All prior authorization criteria are reviewed by the Pharmacy and Therapeutics (P&T) committee.

    The physician should submit clinical information to Premier Health Plan. Once that information is received, a decision regarding the medical necessity of the requested medication will be made.

    Step Therapy

    Step therapy ensures that patients are taking the most effective medication at the best cost. This means trying the least expensive medication that has been proven to treat a condition. Premier Health Plan’s Step Therapy process includes

    • Step 1: When your prescribed drug is impacted by step therapy, the patient will be asked to try generic or preferred brand drug(s) first. The generic or preferred brand drug(s) recommended has been approved by the Food and Drug Administration (FDA) as providing the same health benefits at a much lower cost.
    • Step 2: If the Step 1 drug(s) does not work, patients can try the requested drug.

    Step Therapy is coordinated with the patient’s benefit plan. Medications are automatically approved if there is a record that the patient has already tried the preferred medication(s).

    If there is no record of a preferred medication in the patient’s medication history, the physician must submit clinical information to Premier Health Plan. Once that information is received, a decision regarding payment for the requested medication will be made.

    Once-Daily Dosing

    To improve patient health through adherence to medication regimens, Premier Health Plan requires once-daily dosing for certain medications.

    If your patient needs multiple daily doses, call Pharmacy Services from 8:00 am to 5:00 pm, Monday – Friday, at the number below:

    Premier Health Employee Plan (855) 266-0713(855) 266-0713

    Quantity Limits

    A quantity limit or dose duration may be placed on certain medications to ensure patients are getting the most cost-effective drug/dose combination.

    Premier Health Plan follows the FDA and manufacturer’s recommended dosing guidelines and limits how much of the medication the member may receive in a certain time period. Providers are encouraged to incorporate these quantity limits into their prescribing patterns.

    For medical exceptions, call Pharmacy Services from 8:00 am to 5:00 pm, Monday  Friday, at the number below

    Premier Health Employee Plan (855) 266-0713(855) 266-0713

    In order to support your exception request, please provide the patient’s diagnosis and tried and failed therapies including the length of time the patient utilized the tried and failed therapy. In addition, supporting chart documentation, including a specialist consult, if warranted, and lab information (i.e., metabolic panel, viral load, etc.) is necessary to review your request.

    Mandatory Generics

    Most formularies require the use of a generic version of a drug if one is available.

    Premier Health Plan Pharmacy Program

    The Premier Health Plan Pharmacy Program offers a five-tier formulary. Many medications, unless they are benefit exclusions, are reimbursed under this program. This allows for accessibility of multiple medications within a class and permits members and providers to determine the medication that is best for the individual member.

    The first and second tiers

    The first tier consists of preferred generics and has the lowest copay. The second tier is made up of non-preferred generics and has a slightly higher copay. These are therapeutically equivalent to the branded products and approved by the FDA. When a generic medication is available, providers are encouraged to prescribe the generic medication to their patients.

    The third tier

    The third tier has a slightly higher cost share and includes preferred brand-name drugs and higher cost generics. Premier Health Plan has designated these agents “preferred” based on clinical efficacy, safety profile and cost effectiveness.

    The fourth tier

    The fourth tier includes brand-name medications or high cost generics that are not preferred but that the member may purchase at a higher cost share.

    The fifth tier

    The fifth tier includes specialty or high cost medications. This tier includes high cost and biological medications regardless of how the medication is administered (injectable, oral, transdermal or inhalant). These medications are often used to treat complex clinical conditions and usually require close management by a physician because of their potential side effects and the need for frequent dosage adjustments. These drugs have the highest cost share.

    Additional information about the Premier Health Plan Pharmacy Program

    Premier Health Plan’s pharmacy benefit is designed to provide patients with coverage for medications at an affordable cost.

    Generics

    To achieve this goal, the patient is required to use a generic version of the drug if one is available. If Commercial or Exchange patients receive a brand-name drug when a generic is available, the patient must pay the cost share amount in addition to the retail cost difference between the brand-name and generic forms of the drug.

    Quantity Limits

    Quantities are limited to a 30-day supply for medications defined as specialty. A 90-day supply of most drugs is available from the CVS Mail Order Pharmacy. The CVS customer service center is available 24/7 at:

    Premier Health Employee Plan (800) 551-5681(800) 551-5681

    Formulary

    To determine what drugs are covered on the formulary, please visit Find a Medication. This is a listing of the formularies which includes the most commonly prescribed drugs and represents an abbreviated drug formulary that is at the core of this pharmacy benefit plan. Please remember that there are many other drug categories and drugs that the plan covers besides the ones listed on this website. Benefit exclusions may apply. Call Pharmacy Services for more information at the number below:

    Premier Health Employee Plan (855) 266-0713(855) 266-0713

    Where to Obtain Prescriptions

    Short-term medications: These are drugs needed immediately. This includes medications used to treat short term infections or to relieve pain temporarily. Members can take these prescriptions:

    Premier Health Employee Plan:

    • To a Premier Health pharmacy.
    • To a retail network pharmacy: Premier Health Employee Plan uses the CVS Advanced Choice Retail Network or members to obtain prescription drugs.

      Long-term medications: These are drugs taken on a regular basis. Members can fill these prescriptions:

      Premier Health Employee Plan:

      • At a Premier Health pharmacy: Premier Health pharmacies can fill prescriptions for up to a 90-day supply. Often times, your Premier pharmacy may have a lower copay for the member’s medication.
      • Through home delivery from the CVS Mail Order Pharmacy: Members may also receive home delivery for long-term medications from CVS. These medications will be delivered directly to the member’s home in a plain, weather-resistant pouch for privacy and protection. Standard shipping is free.

        Specialty medications: Specialty medications treat specific medical conditions such as cancer, hemophilia, hepatitis, multiple sclerosis, psoriasis, pulmonary arterial hypertension, respiratory syncytial virus, rheumatoid arthritis and more.

        Premier Health Employee Plan:

        • To a Premier Health pharmacy
        • CVS Specialty Pharmacy: Patients should call (800) 237-2767 (800) 237-2767 to learn more about specialty medications.