Drugs listed in the Preferred Drug List (PDL) as Office/Clinic Administered 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 are oral or injectable medications that in general cost more than $600 for a 30-day supply. All Specialty drugs require prior authorization for coverage and are limited to a 30-day supply through WHA's exclusive specialty pharmacy network. This network includes Accredo (Express Scripts' specialty pharmacy), and Dignity Health on site pharmacies. WHA will allow up to two initial fills at local retail pharmacies to make sure you get started on your medications in a timely manner. All other fills will be limited to WHA’s specialty network. Please refer to your Copayment Summary for specific copayment amounts.
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.
Self-injectable medications, except insulin, are covered under your WHA medical plan and always require prior authorization from WHA or your Medical Group. These medications (excluding insulin) are limited to a 30-day supply. If the self-injectable medication is approved, all related supplies will also be approved. Insulin and related supplies are covered under the prescription plan and do not require prior authorization.
- Prescriptions filled at retail pharmacies are limited to a 30-day supply.
- Mail order prescriptions allow for a 90-day supply.
- Certain medications do not allow for refills by California law.
- Stimulants for children with ADD may have a 60-day supply when filled at a retail pharmacy.
- Sedative hypnotics are limited to 21 doses per 30-days without prior authorization.
Substituting a Generic Medication
Under your plan, Generic medications are required. If your physician determines there is a need for a brand name drug the physician will need to specify “Dispense as Written” on the prescription as required by the California Board of Pharmacy regulations. The applicable brand name copayment will apply.
When the preferred drug doesn’t meet a member’s clinical needs, WHA considers the drug requested an “exception” based on medical necessity that requires prior authorization and a review for medical necessity. Approval or denial of such requests is the responsibility of the contracted medical group and in some instances WHA.
The physician will need to provide information regarding the alternative drugs that have been tried and failed, or had unacceptable side effects. In the case where the physician feels there is a need for a dosage that exceeds the dosage approved by the Federal Drug Administration (FDA), additional documentation will need to be submitted before the requested dosage will be approved.
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.
WHA uses a Preferred Drug List and a Four-Tier Copayment Plan, rather than a closed formulary. The four tiers are:
- Tier 1 – Preferred Generic Medications
- Tier 2 – Preferred Brand Name Medications
- Tier 3 – Non-Preferred Medications
- Tier 4 – Specialty Medication.
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 small number of drugs, regardless of tier level that may require Prior Authorization to ensure appropriate use based on criteria set by the WHA 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 other 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.
Note: University of California Employees (Does not include UC Residents/Medical Students): Members are required to pay the difference between a brand-name and a generic drug plus the generic copay, when the generic is available. (Exceptions for medical necessity are available via prior authorization, if approved, the applicable brand copay applies.)
Any drug that is undergoing investigational testing in humans requires case-by-case review. Treatment Investigational New Drugs (INDs) are approved by the FDA for use on patients with serious and immediately life threatening diseases for which no other drug or therapy exists and must be reviewed on a case-by-case basis. INDs are not eligible for routine WHA coverage since they are not approved by the FDA for commercial marketing or general use.