You have choices. Understanding them will help you make informed health care decisions.

 Your prescription benefit provides you with many choices. This information is meant to help you understand those choices. It will also enable you to ask you doctor or pharmacist the right questions regarding your medication needs. Our goal is to provide information that will help you make informed decisions regarding medications for you and your family.

 The prescription benefit is designed to provide you with a comprehensive selection of prescription drugs. Together with your doctor, you may refer to the lists below to consider your choices and select the appropriate medication to meet your needs. Keep in mind that your Certificate of Coverage defines your actual benefit coverage and may exclude coverage for certain drugs listed in the PDLs.

We offer two seperate prescription drug list formularies that are chosen by your employer for your benefit plan. To verify the drug coverage you have you can contact PHP's customer service at 1.800.832.9186 or online at www.express-scripts.com. Pharmacy benefits are provided by Express Scripts Incorporated formerly known as Medco Health Incorporated.

• Physicians Health Plan Custom Commercial Member Prescription Drug List
• Physicians Health Plan Essential Commercial Member Prescription Drug List

Note: Coverage is determined by the member's prescription drug benefit.
These lists are subject to change.

 Through Express Scripts (formerly known as Medco) Mail Order, you can get a 90-day supply of certain maintenance medication for only $10!  $10 Maintence Medication Flyer

Our providers are educated to prescribe any drug that is deemed medically appropriate for the patient from the PDL. To obtain access to non-PDL medications, providers can request prior authorization in writing. Members can initiate the prior authorization request via email or phone but pertinent medical information required to process the request must be obtained by PHP from your Physicians office.The prior authorization criteria were developed with input from physicians as well as from current medical literature. Providers may call Customer Service at 1.800.832.9186 or 517.364.8500 and ask to be faxed a prior authorization request form.  The provider should complete the form and fax it back to our on-site Pharmacy department at 517.364.8413.  The provider will be notified of the decision to approve or deny the request.  If a request is denied, alternatives will be suggested. 

 Medications listed on the PDL are covered drug products, selected according to safety and quality standards first, then by cost effectiveness. The PDL contains more than 800 drugs, representing multiple therapeutic needs. The PDL often requires the use of generic drugs. 

You may access your prescription benefits online at www.express-scripts.com. You will have to register the first time that you use the Express Scripts website. Once registered, you will have the ability to verify coverage for a prescription, determine what your co-pay will be if the medication is covered and refill a mail-order prescription.

You will also be able to use a complimentary cost-saving program called My Rx Choices that provides you and your doctors with available lower-cost options to the medications that you are currently taking on an ongoing basis. With My Rx Choices, you and your doctor can make the most informed decisions based on health and cost. No prescription is ever changed without your doctor’s approval.

If you have questions about your prescription benefit contact Customer Service at 517.364.8500 or 800.832.9186 or you can visit the Express Scripts website at www.express-scripts.com to view your prescription benefits online.

Step Therapy (ST) requires you try one medication first to see if it is effective before "stepping" to another medication. The first step is usually a preferred medication. If the first step medication is not effective for you, then you may be able to "step" to the next medication. If your Physician or Provider believes that the "first step" medication will be ineffective or may be harmful, this requirement may be waived if a prior authorization is requested and approved.

Physicians Health Plan works to provide the highest quality of healthcare coverage possible in the most cost-effective way. In support of this philosophy, PHP offers a variety of prescription drug benefit packages to its employer groups.

If your group insurance plan with PHP includes a pharmacy benefit, your employer may offer a single-, two-, or three-tier drug benefit program. Each drug benefit program works with the Prescription Drug List (PDL). Understanding how the PDL and different tier benefit programs work will help you make the most of your pharmacy benefit.

What is a Prescription Drug List?

The PDL is a list of generic and brand-name prescription medications that can be used for conditions treated outside of a hospital. The Food and Drug Administration has approved all drugs on the list. A team of doctors and pharmacists meets regularly to review and update the list. Generally, all drugs will fall into one of three categories:

First Tier - generic drugs on the PDL
Second Tier - brand-name drugs on the PDL
Third Tier - any drugs not on the PDL

Types of Prescription Benefits

Outlined below are the current options available to employer groups who purchase a prescription drug benefit from PHP. Several copayment combinations are offered within each of these options. Please call PHP Customer Service at 517.364.8500 or 800.832.9186 if you are unsure of which benefit you have, or if you would like to check your copayments.

Single-Tier Benefit

On the single-tier benefit, you have one co-payment for brand-name or generic drugs on the PDL. Prescription drugs that are not on the PDL are not covered unless prior approval is granted. Be certain to ask your doctor to prescribe a medication that is on the PDL whenever possible. Most Single-Tier Benefits have an ancillary fee for brand-name medications that have a generic available.


Two-Tier Benefit
There are two copayments available on the two-tier benefit. Generic drugs (first tier) on the PDL will always have the lowest copayment, and brand-name drugs (second tier) on the PDL have the higher copayment. If you are prescribed a brand-name drug that has a generic available, you can choose the lower copayment by opting for the generic drug. If you select a brand-name drug on the PDL, you will pay the higher copayment. Prescription drugs not on the PDL are not covered unless prior approval is granted. You can request that your doctor consider prescribing a medication that is on the PDL.

Three-tier Benefit
The three-tier benefit has three different copayment options. Generic medications on the PDL have the lowest copayment. If you are prescribed a brand-name drug that has a generic available, the generic must be dispensed to receive the lowest (first tier) copayment.
If you select a brand-name drug on the PDL, you will pay a higher copayment (second tier).
With a three-tier benefit, you have access to almost all FDA approved prescription drugs - even those not on the PDL. However, you will pay the highest copayment for any drugs not on the PDL (third tier).
When your doctor prescribes medications from the PDL, you receive the most value from your prescription drug benefit.
 

For questions and/or concerns for the Pharmacy Department regarding a medication and/or authorization for medication you can contact the staff via email or you can call during normal business hours:

Monday through Friday from 8:00 a.m. – 5:00 p.m.

The toll free line is:   877.205.2300

The local line is:       517.364.8545

•Members can initiate the prior authorization request via email or phone but pertinent medical information required to process the request must be obtained by PHP from your Physicians office.