A formulary is a list of prescription drugs that PHP encourages our doctors to prescribe when appropriate. This formulary was developed with the help of area doctors and pharmacists. The formulary is updated quarterly and may change at any time.
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Our Customer Service Department can provide drug formulary information, or you may check for formulary information listed at www.phpni.com. All PHP participating doctors and pharmacies automatically receive a copy of the drug formulary each year along with updates throughout the year.
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Health plans use formularies to manage the cost of pharmaceutical healthcare. Formulary guidelines and protocols are used to encourage doctors to prescribe according to a predetermined therapeutic strategy developed by local health professionals.
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A doctor may prescribe a prescription drug that is not on the PHP formulary. The member has the option to receive the non-formulary medication at a higher pharmacy copayment or to ask the doctor for a formulary medication.
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Our drug formulary was developed by the PHP Pharmacy and Therapeutics Committee, which is comprised of physicians from various medical specialties. The committee reviews medications in all…
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A tiered copayment benefit means there are several possible copayment levels. A member’s copayment is based on the prescription drug being purchased. For example, the first tier represents a preferred generic drug that has the lowest copayment.
Traditional Drugs
- Tier 1 Preferred Generic: Covered drugs that are no longer protected by a drug company patent allowing other drug companies to manufacture equivlant versions of the same drug at a reduced cost.
- TIER 2 Non-Preferred Generic: Similar to Tier 1 covered drugs, but available with a higher copayment.
- TIER 3 Brand Formulary: A list of brand-name drugs that PHP participating network doctors are encouraged to prescribe, when appropriate, for treatment of a medical condition.
- TIER 4 Brand Non-Formulary: Covered drugs that are not included in the formulary listing. You may obtain non- formulary brand-name drugs with a higher pharmacy copayment.
- TIER 5 Specialty Drugs: Specialty drugs are generally injectable, high-cost medications, which you may obtain through our specialty pharmacy, unless administered by a PHP network provider.
If you or your doctor want a brand name drug when there is a generic drug available, you will have to pay more than the formulary or non-formulary brand copayment.
Speciality Drugs
- Tier 1 Preferred Speciality Drugs*: These medications can be injectables or orals that are extremely expensive, must be fulled at a specialty pharmacy, and may need special instructions and handling.
- TIER 2 Specialty Drugs: These medications can be injectables or orals that are extremely expensive, must be fulled at a specialty pharmacy, and may need special instructions and handling.
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Some medications may be subject to quantity level limits based on the manufacturer's packaging insert. These Quantity Limits are designated in the Drug Formulary by (QL) next to the medication name. The purpose of these maximum quantity limits is to ensure the proper billing of products. It also encourages the use of therapeutically indicated medication regimens.
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We would like to take this opportunity to welcome you and your staff to our participating provider network. PHP offers many online tools to assist you, find out more!
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