Pharmaceutical Management

Pharmaceutical Management

Drug Benefits

Drugs listed in the Preferred Drug List (PDL) as Office Administered (OA) are NOT covered under your pharmacy benefit. These medications must be supplied and administered by your doctor's office or by the Medical Group's infusion center.

Specialty Drugs

Specialty drugs are oral or injectable medications that the Food and Drug Administration (FDA) or drug manufacturer requires to be distributed through specialty pharmacies, require the enrollee to have special training or clinical monitoring, or cost more than $600 for a 30-day supply. Most Specialty drugs require prior authorization for coverage and are limited to a 30-day supply through Optum's Specialty Pharmacy. You can order prescriptions online at westernhealth.com/pharmacy-information, or by contacting OptumRx Customer Service at 844.568.4150. Please refer to your Copayment Summary for specific copayment amounts.

Infertility Medications

Infertility medications are only covered when the member’s employer has purchased a separate policy called the Infertility Rider. All infertility services require medical group prior authorization for the services and WHA prior authorization for the infertility drugs. Please refer to your Copayment Summary for restrictions and exclusion for infertility services.

Over the Counter (OTC) Drugs

When your doctor writes a prescription for insulin and/or diabetic supplies, they are covered under your pharmacy benefit. OTC birth control for women is also covered. No other OTC products are covered. Refer to your EOC/DF for details regarding covered drugs.

Quantity Limitations

• Prescriptions filled at retail pharmacies are limited to a 30-day supply.
• Maintenance medications are available for up to a 100-day supply by mail order through OptumRx or up to a 90-day supply at a retail Participating Pharmacy. 
• Certain medications do not allow for refills by California law.

Substituting a Generic Medication

Generic medications are required. The pharmacist may automatically substitute an equivalent generic medication for the prescribed brand name medication (Tier 2 or Tier 3) unless the physician writes “do not substitute” or “prescribe as written,” or there is not a generic equivalent available. In these cases, the member will be provided the brand name medication as written by the member’s physician, even if a generic is available. Regardless of medical necessity or generic availability, the member will be responsible for the brand name (Tier 2 or Tier 3) copayment when a brand name medication is dispensed. If a generic medication is available and the member elects to receive a brand name medication without medical indication from the prescribing physician, the member will be responsible for the difference in cost between generic and brand name in addition to the applicable copayment. The amount paid for the difference in cost does not apply to the deductible or contribute to the out-of-pocket maximum. 

Formulary Exceptions Process

Drugs not listed on the formulary may be covered if WHA approves an exception request. To submit an exception request, please contact your Participating Provider. Your Participating Provider will need to submit a prior authorization request on your behalf for the drug you are seeking a formulary exception. When there is an exceptions request, there are timelines that must be met to resolve the issue and there is an appeal process available to the member.

Formulary/Preferred Drug List

WHA uses a Preferred Drug List and a Four-Tier Copayment Plan. The four tiers are

1. Tier 1 – Preferred generic and certain preferred brand-name medications
2. Tier 2 – Preferred brand name and certain non-preferred generic medications
3. Tier 3 – Non-preferred (generic or brand) medications
4. Tier 4 – Specialty Medications, drugs that require special training or clinical monitoring, and drugs that cost more than $600 per month

Preferred Generic Medications are covered at the lowest Copayment level. Preferred Brand Name Medications are provided at the second Copayment level. Non-preferred drugs are covered at the third tier Copayment level. Specialty Medications are covered at a percentage copayment basis (refer to your Copayment Summary for details).

There are a number of drugs, regardless of tier level that may require Prior Authorization to ensure appropriate use based on criteria set by the Pharmacy and Therapeutics (P&T) Committee. Please note that a drug’s presence on the WHA PDL does not guarantee that the Member’s Physician will prescribe the drug.

Drugs are evaluated regularly, to determine the additions to and possible deletions from the PDL, and to ensure rational and cost-effective use of pharmaceutical agents, through the P&T Committee, which meets every month. Physicians may request that the P&T Committee consider adding specific medications to the PDL. The Committee reviews all medications for the efficacy, quality, safety, similar alternatives, and cost of the drug in determining the inclusion in the PDL.

Biologics/Biosimilars

Biologics are medications made from natural and living sources like animal or plant cells. 
A biosimilar is a medication that is highly similar to a biologic already approved by FDA – the original biologic (also called the reference product). Biosimilar drugs work as well as the original biologic. They are both approved by the U.S. Food and Drug Administration (FDA), have the same treatment benefits and same possible side effects. Biosimilars may be available at a lower cost than the original biologics. If you do not switch to a preferred biosimilar, you may pay the full cost of the biologic for any refills.

COVID-19 Products

WHA covers COVID-19 vaccinations with no cost-sharing when provided at a Participating Pharmacy or through a Participating Provider. COVID-19 medications are covered with no cost-sharing when obtained through a Participating Pharmacy or Participating Provider. WHA will reimburse members for the cost of up to eight (8) FDA-approved at-home COVID-19 test kits per month at a maximum reimbursement of $12 per kit (including tax and shipping if applicable) when obtained at a Participating Pharmacy.

Continuity Drugs

If WHA moves to exclude a drug that was previously covered and provided to a member, WHA will continue to provide the drug as long as it was previously approved by WHA and continues to be prescribed by the prescribing provider, and the drug is appropriately prescribed and is safe and effective for the member’s medical condition, as required by law.

Investigational Drugs

Medications that are experimental or investigational are excluded, except for life-threatening or seriously debilitating conditions and cancer clinical trials.