General Formulary Questions

Specialty Formulary

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What is a Formulary?

The Physicians Plus Drug Formulary is a list of safe, effective and cost-effective drugs. These are the drugs that are covered under your Physicians Plus prescription benefits. Not all prescription drugs are listed on the formulary, these drugs are not covered by Physicians Plus.

Drugs may fall into the following categories:

  • Preferred: Drugs that are placed at the lowest cost generic or brand level. These drugs may be restricted before coverage is available.
  • Non-preferred: Some drug plans have coverage for non-preferred drugs at the highest available formulary level (Tier). Lower cost formulary alternatives are available.
  • Restricted: Drugs that require Prior Authorization or Step Therapy before coverage is available. Restrictions can apply to any brand or generic and preferred or non-preferred drug.
  • Excluded: Drugs or groups of drugs that are not covered under your Physicians Plus prescription benefit. Examples include: drugs to treat hair loss, sexual dysfunction or drugs for cosmetic use. Most over-the-counter (OTC) medications are also excluded.

Where can you find your Drug Formualry?

View the Physicians Plus Drug Formualry three ways:

How is the Formulary Developed?

The Quartz Pharmacy and Therapeutics (P&T) Committee is responsible for creating and maintaining the drug formulary. This committee is made up of physicians and pharmacists who provide care for Physicians Plus members. The P&T Committee meets quarterly to review medications and determine formulary status, clinical restrictions and criteria for coverage.

A detailed medication review is performed by our Clinical Pharmacists based on efficacy, comparative studies, safety, drug interactions, side effects, pharmacokinetics and cost-effectiveness. During the review, a pharmacist researches clinical evidence sources, including Food and Drug Administration (FDA) drug data, Facts and Comparisons, clinical practice guidelines, peer reviewed or scholarly articles written by professional experts. Local practitioners are also contacted to provide direction on drugs related to their specialty.

The Phsyicans Plus Drug Formulary is updated monthly. Most changes involve adding new drugs or drugs that are newly available in generic form. At times, drugs are removed from the formulary or moved to restricted status. Check the website or request an up-to-date version from Customer Service.

Quarterly formulary updates are listed on the Formulary page.

How to use the Formulary

What information does my retail pharmacy need to bill my prescriptions?

Your pharmacy will need the RxBIN,RxPCN, and RxGroup numbers shown on your ID card.

For plans underwritten by Physicians Plus, you can provide the information shown below -

  • BIN: 003858, PCN: A4, Group: PPLUSIC

How do I know what my copay will be for my prescriptions?

You can search by drug name in your plan's Drug Formulary to find the drug's level of coverage (Tier). Your Summary of Benefit document will show your benefit's cost share by Tier.

Which formulary do I use?

A: You can view your Summary of Benefits document to find the formulary your plan references. To find your Summary of Benefits document, login to: https://mychart.pplus.com/mychart/

After login:

  • Select MyPlan, then
  • Insurance Summary, then
  • Current Plan link

Under the Documentation section, select the link for Summary of Benefits & Coverage

Does my prescription require a Prior Authorization?

Search by drug name on the Drug Formulary to see if "PA" is shown in the Special Codes column.

How do I initiate the Prior Authorization process?

Contact your prescriber's office to request a Medication PA Request Form be submitted directly to Pharmacy Services. This will ensure the correct prescriber contact information is used and the needed clinical documentation will be provided.

Where can I fill my prescription while out of town?

You can search for a network pharmacy by zip code or city, state.

Can I fill more than one month supply at a time?

Yes, most medication qualifies for up to a 90 day supply. Specialty drugs, Antibiotics, and drugs classified as Controlled Substances do not qualify for a 90 day supply.

I paid out of pocket for a drug that should've been covered under my insurance, how do I request a refund?

Send the Direct Member Reimbursement Form along with your pharmacy leaflet and receipt to Pharmacy Services directly using the contact information shown on the form.

Where can I fill my Specialty medication?

The Physicians Plus Specialty Pharmacy Network includes Accredo, UnityPoint Health - Meriter, and UW Health Specialty pharmacies. Contact information is shown on our Specialty Pharmaceuticals page.

How can I start filling my Specialty drug?

All Specialty drugs require prior authorization. Once you have been approved, you can contact the specialty network pharmacy of your choice directly to set up your account.

Additional Specialty Network related frequently asked questions found here.

Please contact Physicians Plus Pharmacy Services at (800) 545-5015 or (608) 260-7803 for assistance with any of your pharmacy benefit related questions.

 


This health plan is underwritten by Physicians Plus Insurance, Inc.