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Pharmacy Coverage

PHP Care Preferred has a List of Covered Drugs, also known as a Formulary.

When you get a prescription for any of these covered drugs, PHP Care Preferred will cover the prescription when you go to a network pharmacy. (Some drugs have limits – see Limits on coverage for some drugs below).

PHP Care Preferred has more than 5,000 retail pharmacies across their nine-county service area. You can always check our pharmacy directory for a network pharmacy near your home.

PHP has partnered with Alliance Rx Walgreens Prime to offer participants with a mail order pharmacy program.  If you are on any maintenance medications, you can conveniently have up to a three-month supply delivered to your home.  Maintenance medications are used to treat chronic illnesses.

Our Formulary has one tier and includes drugs covered under your Medicaid benefits.  Each drug has a $0 copay.   You can contact us at Participant Services 1-855-747-5483 or TTY/TDD: 711 for the most recent drug list.

For Pharmacy Member Services, Pharmacy Technical Help Desk, or Pharmacy Prior Authorizations, please call 1-833-669-7673.

Limits on coverage for some drugs

For certain prescription and covered over-the-counter (OTC) drugs, special rules limit how and when we cover them. In general, our rules encourage you to get a drug that works for your medical condition and is safe and effective.

  1. Step Therapy: Trying a different drug first

In general, we want you to try lower-cost drugs (that often are as effective) before we cover drugs that cost more. For example, if Drug A and Drug B treat the same medical condition, and Drug A costs less than Drug B, PHP Care Preferred’s rules may require you to try Drug A first. If Drug A does not work for you, the plan will then cover Drug B. This is called step therapy.

  1. Quantity limits

For some drugs, we limit the amount of the drug you can have. For example, the plan might limit:

  • how many refills you can get, or
  • how much of a drug you can get each time you fill your prescription.
  1. Prior Authorization

For some drugs, we may ask your prescribing doctor to get prior approval from PHP Care Preferred before we can have the pharmacy dispense the drug to you.  This is called prior authorization.

What if I’m taking a drug that is not on PHP’s formulary?

If you are a new PHP Care Preferred member and are currently taking a drug that is not on PHP’s formulary but otherwise meets the definition of a non-Part D drug covered by Medicaid (including formulary drugs that require prior authorization or step therapy), PHP will continue to pay for the drug on a temporary basis (i.e., 90 days).

Generic Substitution

A pharmacist will fill a generic drug rather than a brand-name drug, unless your prescriber writes “DAW” (Dispense As Written) on your prescription. A generic drug should have therapeutic equivalence to the brand-name drug. Your prescriber may request prior authorization for a brand-name drug if they feel a brand-name medication is necessary for you.

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