Explanation of Benefits
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.
For medications to be covered by the plan, they must be:
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:
If a medication is not on the formulary, an exception can be made if:
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.
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.
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, view our list of medications that require preauthorization, or log into your member portal or provider portal to view the formulary.
Specialty medications are typically used to treat complex medical conditions. These medications may require frequent dosing adjustments, close monitoring, special training, or compliance assistance. In addition, specialty medications may need special handling and/or administration, and may have limited or exclusive product availability and distribution. Specialty medications can be obtained through: in-network retail pharmacies located within the state of North Dakota, Sanford Specialty Pharmacy, Optum Specialty Pharmacy, or Monument Health Specialty Pharmacy.
By following the formulary and asking your provider for generic medications when available, you will save money and help control the costs of your healthcare. If you request a brand name medication when there is an equivalent generic alternative available, you will be required to pay the price difference between the brand and the generic product, in addition to any copay and/or cost-share as determined by your plan benefits.
Medication may be limited to a certain quantity.
If you or your health care practitioner feel that a certain medication is medically necessary for your condition, an exception may be available. To request a formulary exception, please contact the Pharmacy Management Department:
Members must first try formulary medications before an exception to the formulary will be made unless the prescriber and the plan determine that use of the formulary drug may cause an adverse reaction or be contraindicated. If an exception is granted, coverage of the non-formulary drug will be provided for the duration of the prescription, including refills. If your request is not granted, you have the right to appeal.
Medications that have a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force and only when prescribed by a health care practitioner and/or provider are available at a $0 copay (no member cost-share) if the member meets specific conditions, such as age or gender. If the member does not meet the specific conditions, the usual member benefit will apply.
Medications covered under the medical benefit that are subject to the medical deductible, coinsurance and maximum out of pocket.
To promote value optimization, the formularies generally endorse the use of generic medications over their brand counterparts, whenever possible. Where most substitutions for generic/therapeutic interchange occur outside the purview of the health plan, specific policies related to brand ancillary penalties are maintained separately. The purpose of these policies is to standardize the review process for cases where a brand may be medically necessary, in order to bypass these ancillary penalties.
The Plan updates the formulary on an annual basis and as needed when new drugs enter the market or when a drug is removed from the market, as described in the Pharmacy and Therapeutics Committee’s responsibilities.