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Pharmacy

The SCFHP drug formulary is a list of preferred generic and brand-name medications in various therapeutic classes that are covered under the SCFHP pharmacy benefit. The Drug Formulary (List of Covered Drugs) exists to allow our providers and clinicians to determine the safest and cost-effective drug therapy possible.

For the Cal MediConnect formulary, please visit the Cal MediConnect List of Covered Drugs page.

The Formulary Drug List applies only to drugs provided by a retail, long-term care or home infusion pharmacy and processed through SCFHP’s Pharmacy Benefit Manager (PBM). It does not apply to drugs used in inpatient settings or furnished by a provider.

Resources

Pharmacy Benefit Manager (PBM)

SCFHP's PBM is MedImpact. Pharmacies can contact MedImpact directly for the following:

  • One-time vacation overrides
  • Three-day emergency supply overrides
  • Lost or stolen medication overrides
  • Refill too soon override due to change in dose
  • Billing questions
  • Price restriction overrides

MedImpact Customer Service Center: 1-800-788-2949

Pharmacy and Therapeutics (P&T) committee

The SCFHP Pharmacy and Therapeutics (P&T) 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 P&T Committee reviews the Formulary Drug List and updates it 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. DHCS defines a 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

Claims with dollar amounts greater than $5,000, specialty claims with dollar amounts greater than $25,000, and compound claims with dollar amounts greater than $150 will be rejected 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 should call 1-800-788-2949 or 1-408-874-1796. The MedImpact/SCFHP staff shall verify that the pharmacy is billing correctly and enter an override if appropriate.

Emergency supply benefit

If a contracted pharmacy cannot fill a prescription, and the medication is urgently needed, SCFHP allows the dispensing of up to a 72-hour 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. The pharmacy may call the MedImpact Pharmacy Help Desk at 1-800-788-2949 to request up to 3-day supply override. The Pharmacy Help Desk is available 24 hours, 7 days a week.

Please note that there are some drugs that do not qualify for an emergency fill. Drugs excluded from coverage do not qualify for an emergency fill.

Formulary exclusions

The following are excluded:

  • Not approved by the United States Federal Drug Administration (FDA)
  • Used as experimental
  • Dietary supplements and medical foods
  • Used to treat infertility
  • Used to treat sexual dysfunction
  • Used for cosmetic reasons
  • Drug Efficacy Study Implementation (DESI) products
  • Bulk chemicals including those used for compounding
  • Drugs covered by Fee-For-Service (FFS) Medi-Cal or California Children’s Services (CCS)

Prior authorization (PA) process

SCFHP encourages providers to prescribe formulary drugs whenever possible. However, when a provider elects to prescribe a non-formulary drug, a Prior Authorization or Step Therapy Exception Request Form must be completed by the 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 hours as long as all of the information required to make a decision has been provided.

Incomplete or illegible forms will be returned for clarification or additional information. If a prior authorization request is approved, the pharmacy may adjudicate the claim at point-of-sale. For all other related PA status or questions, please call the SCFHP Pharmacy Department at 1-408-874-1796, Monday to Friday 8:30 a.m. to 5:00 p.m. excluding holidays.

Drugs administered by physicians/clinics

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

Specialty drugs are high-cost drugs that may be used to treat complex medical health conditions. Prior authorization is required prior for most specialty drugs. SCFHP uses a specialty pharmacy network. For more information, please call SCFHP’s specialty pharmacies for more information:

Disclaimer

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 questions on coverage of any medication, please contact SCFHP’s Medi-Cal Pharmacy Department at at 1-408-874-1796.