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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. Visit www.valleyhealthplan.org​ or call VHP Member Services at 1.888.421.8444 (toll-free) to find a list of Plan Pharmacies.

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; Plan cost (net of rebates) is >$600.
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.

Employer Group
 
Plan Retail Pharmacy
​1 to 90 Day Supply
Tier 0 Retail
0 Copay
Tier 1 Retail
0 Copay
Tier 2 Retail
0 Copay
 
 
Costco Mail Service Pharmacy​​
61 to 90 Day Supply​
Tier 0 Mail
0 Copay
Tier 1 Mail
0 Copay
Tier 2 Mail
0 Copay
  
 
Covered California
            and
Individual & Family  
 
Plan Retail Pharmacy
1 to 31 Day Supply
32 to 60 Day Supply
61 to 90 Day Supply
Tier 0 Retail
0 Copay
0 Copay
0 Copay
Tier 1 Retail
1 Copay
2 Copays
3 Copays
Tier 2 Retail
1 Copay
2 Copays
3 Copays
Tier 3 Retail​ 1 Copay 2 Copays 3 Copays
Tier 4 Retail 1 Copay 2 Copays 3​ Copays
 
 
Costco Mail Service Pharmacy
61 to 90 Day Supply
Tier 0 Mail
0 Copay
Tier 1 Mail
2 Copays
Tier 2 Mail
2 Copays
Tier 3 Mail​ 2 Copays
​Tier 4 Mail 2 Copays
 
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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Last updated: 12/14/2018 2:37 PM