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.

Contact Pharmacy Management if you have pharmacy related questions or need additional assistance. After hours you may leave a message on the confidential voice mail and someone will return your call the following business day.

Main Number
(855) 305-5062
Fax: (701) 234-4568
8 a.m. and 5 p.m. Monday through Friday

NDPERS
(877) 658-9194
Fax: (701) 234-4568
8 a.m. and 5:30 p.m. Monday through Friday

ND Medicaid Expansion
(855) 263-3547
Fax: (701) 234-4568
8 a.m. and 5 p.m. Monday through Friday

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. 

Pharmacy Network

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:

• Individual/Small Group Formulary
• 3-Tier Commercial (Large Group/Self-Funded)
• 5-Tier Commercial (Large Group/Self-funded)
• North Dakota Public Employee Retirement System (NDPERS) Formulary
• North Dakota Medicaid Expansion Formulary 2019

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 and failed the formulary option(s); 

To request an exception, the provider must complete the Prescription Drug Prior Authorization Request and 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.

• Prescription Drug Prior Authorization Request and Formulary Exception Form
  
• Synagis – Prescription Drug Prior Authorization Request and Formulary Exception Form

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.

• Medications that require Step Therapy
• Prescription Drug Prior Authorization Request and Formulary Exception Form

Preauthorization
Prior authorization is the urgent or non-urgent authorization of a requested medication prior to receiving the medication. The plan determines approval for prior authorization based on appropriateness of care, service, and existence of coverage. Please see below to learn more about the prior authorization process and what services require prior authorization.

During the prior authorization process, members and providers work together to get approval from Sanford Health Plan to provide coverage for specific medications. Sanford Health Plan's decision is based on a combination of medical necessity, medical appropriateness, and benefit limits. Prior authorization is never needed for emergency care.

• Medications that require Prior Authorization

How to Request Prior authorization
Prior authorizations for medications can be obtained by contacting Pharmacy Management online or fax:

Online: Providers: Select “Authorizations” in your secure mySanfordHealthPlan account at sanfordhealthplan.com/providerlogin. Click on “Submit a Pharmacy Preauthorization”. Once you complete the required information click “Submit.”

Fax:  Fax the Prescription Drug Prior Authorization Request and Formulary Exception Form and supporting documentation to (701)234-4568
Prescription Drug Prior Authorization Request and Formulary Exception Form