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Valley Health Plan

Step therapy, quality limit, and maintenance drugs - Covered CA and IFP

female black patient on telehealth call with caucasian male doctor

 

Step therapy

Selected formulary drugs require step therapy (ST). This means that a Member must try an alternative clinically equivalent formulary drug first. VHP P&T Committee selects all drugs required for step therapy. There may be a situation where it may be medically necessary for a Member to receive certain medications without first trying an alternative drug. In these instances, your Provider may request a Standard California PA form by contacting Navitus Customer Service. The list of formulary drugs with step therapy can be changed by Valley Health Plan’s P&T Committee. An updated list of the formulary drugs with step therapy is available below.​

Quantity Limitation (QL) Program

Because of potential safety and utilization concerns, VHP has placed quantity limitations on some prescription drugs. Members are covered for up to the amount posted in the VHP Drug Formulary based on recognized standards of care and FDA-approved dosing guidelines. If a prescriber believes it is necessary to prescribe more than the QL amount posted on the list, he or she must submit a Standard California PA form to VHP’s PBM. A list of covered drugs with QL is available at www.valleyhealthplan.org or by calling VHP Member Services at 1.888.421.8444 (toll-free).​

Maintenance drug

A maintenance drug is prescribed for a serious chronic illness or condition. The pharmacy can dispense up to a 90-day supply for formulary drugs that are listed on the Maintenance Drug List. You can find the list at www.valleyhealthplan.org​ or by calling VHP Member Services at 1.888.421.8444 (toll-free).  Not all drugs on the Maintenance Drug List may be covered on the Drug Formulary. Always refer to the formulary for a list of current covered drugs. Members can get the maintenance drug through the Plan Pharmacy or Plan mail service pharmacy administered by Novixus.​