Sanford Health Plan gives our members and providers access to the information and support they need. Below is a brief explanation of our pharmacy benefits. For specific details on medication policies, coverage, participating pharmacies and more, log in to your secure Member Portal or our Provider Portal. If you need additional assistance, please contact us between 8 a.m. and 5 p.m. Monday through Friday. After hours, a confidential voicemail is also available.

Medication Benefits

For medications to be covered by the plan, they must be:

• Approved by the Federal Food and Drug Administration (FDA) for use in the United States;

• Prescribed or approved by a physician, advanced practice provider or dentist;
• Listed in the plan formulary, unless pre-approval (authorization) is given by the plan;
• Provided by an in-network participating pharmacy except in the event of a medical emergency; NOTE: If a prescription is filled at a non-participating and/or out-of-network pharmacy and it is not an emergency, the member is responsible for the prescription drug cost in full.

Formulary

Sanford Health Plan has a list (formulary) of FDA approved brand name and generic medications that are covered by the plan.  Selection criteria for medications on the list include effectiveness, safety and cost-effectiveness. Changes are made throughout the year by Sanford Health Plan’s Pharmacy and Therapeutics committee as necessary, with a complete review performed each year. By following the formulary and using generic medications when available, members can save money and help control out of pocket costs.

Sanford Health Plan Formularies:

• Simplicity and TRUE for Individual & Small Groups
• 3-Tier Commercial (Large Group/Self-Funded)
• 5-Tier Commercial (Large Group/Self-funded)
• North Dakota Public Employee Retirement System (NDPERS) Formulary
• 2023 HDHP Preventive Medication List
• HDHP Medication Cost Estimator

If a medication is not on the formulary, an exception can be made if:

• A provider feels it is medically necessary; or
• The member has tried the Step Therapy Program (the member cannot tolerate side effects or use of step therapy drugs is contraindicated).

To request an exception,  the provider must complete the Formulary Exception Form and return to Sanford Health Plan.  The request will be reviewed and the member and provider will be notified of the determination by mail.

Step Therapy Program

Certain medications require step therapy to ensure lower cost and/or generic versions of medication are tried before higher cost alternatives are used. If first step medications do not work or side effects are experienced, the next step may be tried.

Documentation or pharmacy records indicating medications that have been tried for a minimum of 30-days must be supplied before the plan will cover the target medication. This policy only pertains to medications on the formulary; non-formulary medications will be reviewed per Sanford Health Plan’s formulary exception policy.

Preauthorization

Like some services, certain medications must also be pre-approved (preauthorized). To receive pre-approval, providers must submit a letter of medical necessity and supporting medical information. For a list of medications that are covered or those that require pre-approval, click here for a list of medications that require preauthorization, or log into your member portal or provider portal to view the formulary.