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Pharmacy Information for Providers



Pharmacy Information


Prescription Program

Our Prescription Drug Program Policy includes how the formulary is developed and maintained, the prior authorization program, how to pursue an exception, and information on generic substitution and quantity limits. It can be accessed here.

Prescription Drugs

WPS partners with Express Scripts for our plans' prescription drug benefits. For more information on physician services through Express Scripts, visit their physicians' page.

Helpful documents:

WPS Drug Prior Authorization List
This document contains a recent list of drugs that require prior authorization. If your patient needs a drug from this list, please utilize the contact information contained on the Drug Prior Authorization List.


2022 WPS Large Group Formulary
2022 Individual and Small Group Formulary
2022 Short-Term Health Plan Formulary

These documents provide a list of drugs that are preferred by your WPS health plan and are offered at lower copay levels. Drugs are listed alphabetically by drug category and name. This guide provides suggestions on how you can save on prescription costs, safety symbols for drugs not recommended at different ages, during pregnancy, and more.

What is step therapy?

Sometimes, the medical community determines more than one prescription drug is safe and effective for the treatment of the same illness or injury. WPS Health Insurance or WPS Health Plan may require you to start with a less expensive prescription drug before benefits are payable for an alternative prescription drug. This helps ensure your medication is effective and affordable. We refer to this as “step therapy.”

Learn More about step therapy

This information only applies if your pharmacy benefits are managed through Express Scripts Inc (ESI). If you are unsure who manages your pharmacy benefits or do not have pharmacy benefits through ESI, please contact your Human Resources department for more information.

What is a drug formulary?

Most plans come with a drug formulary. A drug formulary is a list of prescription drugs, both generic and brand name, used by practitioners to identify drugs that offer the greatest overall value. A committee of independent, actively practicing physicians and pharmacists maintain the formulary. The formulary can change from time to time.

Please refer to your certificate of insurance or individual policy for additional details about your pharmacy benefit and applicable deductibles, copays, and/or coinsurance.

*All benefits are subject to plan provisions such as medical necessity and exclusions. There is no guarantee of payment and usual and customary fees may apply.

What do the different tiers mean?

Drugs on a formulary are typically grouped into tiers. The tier that your medication is in determines your portion of the drug cost. A typical drug benefit includes three or four tiers:

  • Tier 1 usually includes generic medications.
  • Tier 2 usually includes preferred brand-name medications.
  • Tier 3 usually includes non-preferred brand-name medications.
  • Tier 4 usually includes specialty and biosimilar medications (Three-tier programs do not have a unique tier for specialty medications)

A medication may be placed in tier 3 or 4 if it is new and not yet proven to be safe or effective, or there is a similar drug on a lower tier of the formulary that may provide you with the same benefit at a lower cost.

Note: If you have a federally qualified high-deductible health plan, you do not have a tiered drug benefit; your pharmacy and medical expenses are subject to your deductible and coinsurance. This section does not apply to you.

What are generics and biosimilars?

The active ingredients in a generic drug are chemically identical to their brand name counterparts. When an FDA-approved generic is available, a health plan may limit coverage to the generic, and a pharmacist will dispense the generic medication. If an Arise Health Plan customer requests the brand, he/she will be responsible for the difference in cost between the brand and the generic, plus any applicable deductible, coinsurance, and/or copay.

Note: The cost difference between the brand and generic drug is not considered a covered benefit and does not apply to the deductible or out-of-pocket (OOP) maximum.

Biosimilars are drugs approved by the FDA that have no clinically meaningful differences from the originator brand name biologic agent. They provide the same clinical outcome as the brand originator drug and are usually considered specialty medications from a copay perspective.

What is prior authorization and when is it needed?

Prior Authorization is a process that monitors the use of certain drugs to ensure they are prescribed in appropriate clinical situations. Drugs subject to prior authorization typically have safety issues, a high potential for inappropriate use, and/or have lower-priced alternatives on the formulary.

Drugs requiring prior authorization must meet specific criteria for use before they will be considered a covered benefit. The process usually involves these steps:

  1. Your practitioner submits certain medical information to help us make a decision.
  2. Your practitioner’s office and you are notified as to whether or not the drug is approved.
  3. If a drug prior authorization has been denied or not submitted, your pharmacy will not be able to file the drug claim under your prescription benefit, so you will be responsible for the entire cost of the prescription.

What if my drug isn’t on the formulary (exceptions)?

A drug formulary is a list of prescription drugs, both generic and brand name, used by practitioners to identify drugs that offer the greatest overall value. The formulary does not contain a complete list of all available drugs. In addition, some drugs may require a prior authorization prior to coverage while others may not be covered on the formulary.

We have an exception process for individuals to request coverage of a drug that is not on our prescription drug formulary. You, your authorized representative, or prescribing health care provider may request access to clinically appropriate drugs that are not otherwise covered by the health plan’s drug formulary through an approved exception. An exception request can be requested for both urgent and non-urgent circumstances.

If you would like to initiate a formulary exception through your provider, please have them contact Express Scripts for more information or to start a request.

Why is a formulary drug getting rejected?

The following is a list of common reasons a prescription may not process at the pharmacy.

  • Prior authorization is required but has not been obtained.
  • The pharmacy may be submitting the claim under the wrong family member. For example, a prescription for an oral contraceptive will only process if the family member is female.
  • Some drugs, like migraine medications, are not taken every day. If the pharmacy is submitting a quantity larger than what is allowed, the prescription will not process.
  • Retail pharmacies are only able to dispense up to a continuous 30-day supply of medication. If your pharmacy is trying to dispense greater than this amount, the prescription will not process.

To answer your specific questions, please contact Express Scripts Customer Service for more information.

If your health plan includes a prescription drug home delivery benefit, you can find answers to common questions here.

How do I submit a prescription to the home delivery pharmacy

  1. Obtain a written prescription from your doctor. Make sure your doctor writes the prescription for up to a 90-day supply of your medication (or for the maximum days supply allowed by your benefit). The prescription should include refills for up to one year, if appropriate.
  2. Write the patient’s name, ID number, address and date of birth on the prescription.
  3. Download the Express Scripts® Home Delivery Order Form and follow the instructions.
  4. Attach your written prescription to the form as indicated.
  5. Mail the order form and written prescription to this address:

What if I do not have a written prescription?

Your doctor will need to verify the Patient Information, attach your new prescription, and fax your order to Express Scripts at 1-800-521-5779. This must be faxed from your doctor’s office. Faxes sent from other locations (such as your home or workplace) will not be accepted.

   

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