Drug Benefit Information

Valley Health Plan (VHP) Members have prescription drug coverage. VHP contracts with Navitus Health Solutions, a pharmacy benefit management (PBM) company to administer the prescription drug benefit and process claims. This document supplements your Combined Evidence of Coverage and Disclosure Form (EOC) handbook. Under this supplemental pharmacy benefit document, a member may receive the benefits described below, subject to all terms, conditions, exclusions, and limitations described in the EOC.

Except for certain mandatory specialty prescriptions, a member may get covered outpatient prescription drug benefits from any Plan Pharmacy. Only prescription(s) for emergent or urgent care services will be covered at an out-of-network pharmacy when a Plan Pharmacy is not available. 

Retail Pharmacy Network

• California Raley's and Affiliates​
• Countywide Valley Health Center Pharmacies (VHC)
• Nationwide Walgreens
• Nationwide Safeway/Albertsons affiliates
• Nationwide Costco Pharmacies

• California Pharmacy Directory for Covered California and Individual & Family Plans​

Mandatory Specialty Pharmacy (MSP) 

• ​Valley Medical Center Pharmacy 1.833.543.0744 (toll-free)

• Lumicera Health Services 1.855.847.3554 (toll-free)

Members should always present their VHP ID card to the Plan Pharmacy. Ask the pharmacy staff to let you know if something is not covered. A copay/coinsurance may be charged for covered benefits as listed in your EOC. If the retail price for a prescription drug is less than your copayment, the retail price should be charged.

Employer Group

Covered outpatient formulary medications include:

• Tier 0: Healthcare reform drugs and Vaccines
• Tier 1: Generic drugs on the VHP Drug Formulary
• ​Tier 2: Brand name drugs on the VHP Drug Formulary

Covered California and Individual & Family​

Covered outpatient formulary medications include:

• Tier 0: Birth Control and Health Care Reform Act Drugs.
• Tier 1: Most generic drugs and low-cost preferred brands.
• Tier 2: ​​Non-preferred generic drugs or; Preferred brand name drugs or; Recommended by the plan’s pharmaceutical and therapeutics (P&T) committee based on drug safety, efficacy, and cost.
• Tier 3: Non-preferred brand name drugs or; Recommended by the VHP P&T Committee based on drug safety, efficacy, and cost; or Generally, have a preferred and often less costly therapeutic alternative at a lower tier.
• Tier 4: Food and Drug Administration (FDA) or drug manufacturer limits distribution to specialty pharmacies; or Self administration requires training, clinical monitoring or; Drug was manufactured using biotechnology or;

The FDA has strict standards for identity, strength, quality, purity, and potency before approving a generic drug. When available, the pharmacy is required to switch a brand-name drug to the equal generic drug. A generic drug is identical, or bioequivalent, to a brand name drug in dosage, form, safety, strength, route of administration, quality, performance characteristics, and intended use.

If the prescriber believes a member needs the brand name drug, they must send the PBM a Standard California Prescription Drug Prior Authorization form as well as proof the FDA MedWatch form was submitted to the FDA. If the brand-name drug is determined to be medically necessary, the member will be able to get the drug.

​Some benefit plans have a deductible that applies to a covered prescription brand name or an overall deductible that is combined between medical care and covered prescription drugs. If the benefit plan includes a deductible, the member is responsible for paying all costs to meet the deductible each calendar year. Once the deductible is met, VHP will cover the prescription drugs at the applicable copayment​. Any questions about copays and deductibles please refer to your SBC or call VHP Member Services at 1.888.421.8444 (toll-free).

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