The SCFHP drug formulary is a list of preferred generic and brand-name medications in various therapeutic classes that are covered under the SCFHP prescription drug benefit. The Formulary Drug List exists to allow our providers and clinicians to determine the safest, most effective, and least costly drug therapy possible.
The Formulary Drug List applies only to drugs provided by a retail pharmacy and processed through SCFHP’s Pharmacy Benefit Management (PBM) and does not apply to drugs used in inpatient settings or furnished by a provider. The SCFHP Pharmacy and Therapeutics Committee meets once per quarter to develop and maintain the Formulary Drug List to ensure that the formulary remains responsive to the needs of our members and providers. The committee is composed of physicians from various medical specialties and pharmacists, whose role is to evaluate clinical drug reviews concerning safety, effectiveness, costs, and decide on the most cost-effective drugs in each class.
The Formulary Drug List is reviewed and updated based on comprehensive data on efficacy and safety that is available from evidence-based clinical studies, and for which evidence of performance in overall use in a variety of therapeutic settings has been established. The decisions are also based on the Department of Health Care Services (DHCS) contract requirement stating that the Formulary Drug List shall be comparable to the Medi-Cal Fee for Service list of contract drugs, except for drugs that are carved out through specific contract agreements. The DHCS defines comparable formulary as “it must contain drugs which represent each mechanism of action sub-class within all major therapeutic categories of prescription drugs included in the Medi-Cal FFS list of contract drugs.”
Price Restrictions. Non-compound claims with dollar amounts greater than $500 and compound claims with dollar amounts greater than $50 will reject with messaging “Max Claim Pay Exceeded.” These claims will require an operational prior authorization for review of correct claim submission, dosing, and pricing which justifies the high-cost claim. The dispensing pharmacy may call MedImpact at 1-800-788-2949. The MedImpact staff will ensure that the pharmacy is billing correctly and enter a prior authorization if appropriate.
Emergency Supply benefit. If contracted pharmacy cannot fill a prescription upon the time of service, and the medication is urgently needed, SCFHP allows the dispensing of up to 3-day supply of non-covered medication. This policy has been created to ensure members receive medication in appropriate situations to cover temporary delays that might prevent prescriptions from being filled at the time of service. The dispensing pharmacist will use his/her clinical judgment whether the situation is an emergency. Please call the MedImpact Customer Service Center at 1-800-788-2949 in order to request an up to 3-day supply override.
Brand name drugs that are FDA approved and equivalent generic drugs are available, except select “narrow therapeutic index” drugs;
- Drugs not listed in the Formulary Drug List
- Drugs removed from the Formulary Drug List and approved by the P&T Committee
- All drugs bearing a label: “Caution – limited by federal law to investigational use.” OR experimental drugs.
- Drugs used without FDA approved indications
- Drugs used to promote fertility or to treat sexual dysfunction
- Drugs used for cosmetic indications
- Most Over-The-Counter products
- Most prescription vitamins and minerals, except prenatal vitamins and pediatric multivitamins with fluoride, and fluoride preparations.
- Alcohol, heroin detoxification and dependency treatment drugs (i.e. Suboxone)
- Medi-Cal “Carve-Out” Drugs including HIV-AIDS drugs and Atypical Anti-Psychotic drugs
SCFHP encourages providers to prescribe formulary drugs whenever possible. However, when a provider elects to prescribe a non- formulary drug, a Prior Authorization (PA) Request Form must be completed by the pharmacy or physician and faxed to Santa Clara Family Health Plan at 1-408-874-1444. Determinations of approval or denial for prior authorization requests are provided within 24 business hours as long as all of the required information is met to make a decision. Prior authorization requests will be reviewed during normal business hours (Monday through Friday 8:30 a.m. to 5:00 p.m. PST (Pacific Standard Time)) excluding holidays. Note: for urgent prior authorization requests, please check the “Urgent” box on the PA form.
All required fields of the Prior Authorization Form should be completed to avoid delay in the review of the request. Incomplete or illegible forms will be returned or pended for clarification or additional information. If a prior authorization request is approved, the pharmacy may adjudicate the claim on-line as directed by the PA fax-back message from SCFHP. There is no need for a prior authorization number. For all other related PA status or questions, please call the SCFHP Pharmacy Department at 1-408-874-1796 during business hours.
You may download a copy of the Prior Authorization Form here.
Any drug administered by a physician or clinic, including injectable anti-neoplastic medications, needs to be billed as a medical claim by the physician or clinic and not by the dispensing pharmacy providing the drug for such administration.
Specialty drugs are high-cost drugs that may be used to treat complex medical health conditions. Prior authorization is required prior to drug dispensing. A one-time fill may be obtained at a local retail pharmacy and subsequent refills shall be obtained through a contracted Specialty Pharmacy Network Provider. For more information, please call SCFHP Pharmacy Department at 1-408-874-1796.
A participating physician or pharmacist provider may suggest the addition of a medication to the Formulary Drug List. To request a formulary addition, please complete the “Formulary Addition Request Form” and submit to the address listed below no later than 4 weeks prior to the next P&T Committee meeting:
Santa Clara Family Health Plan
210 East Hacienda Avenue
Campbell, CA 95008
Attention: Pharmacy Department
B/G = Brand or Generic Indicators. Indicates if the drug is available as a brand or generic agent. In some cases certain strengths are only available as brands while other strengths are available as generic. In these cases the designation is dependent on whether more strength is available as brands or generics.
Representative Brand. In some cases there is more than one brand name for the generic equivalent. In these cases, one brand name is used to represent multiple products.
QL = Quantity Limit. Indicates the medication has a quantity restriction. Requests for quantities higher than the indicated amount require prior authorization.
Age Restriction. Indicates that there is an age restriction when obtaining this medication.
ST = Step Therapy. Step therapies indicate that another drug is requested to be tried first before the 2nd line agent will approve online. If the provider feels the first line agent is inappropriate then a prior authorization can be requested.
DS = Day Supply. Indicates the medication can be dispensed for more than a month’s supply
Our formulary is updated by a group of community physicians and pharmacists periodically and therefore the status for any medication may change throughout the year. The benefits are subject to the plan provisions in effect when services are given including patient eligibility and any plan limitations or exclusions. For clarification on coverage of any medication, please contact SCFHP Member Services at 1-800-260-2055.
Provider Services Department Phone1-408-874-1788
Provider Services Department Fax1-408-376-3537