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Understanding Pharmacy Benefits

Drug Formulary

GHC-SCW maintains a list of drugs and certain medical devices covered under the pharmacy benefit. This is known as the Formulary, which is updated regularly. GHC-SCW maintains several Formularies

Please click below to view our drug formularies. You can look up the formulary used by your benefit plan here.

• GHC-SCW 3 Tier Formulary

• GHC-SCW 4 Tier Formulary

• GHC-SCW Marketplace Formulary (sometimes called Metal, Shop or ACA Formulary)

• GHC-SCW ​Mandated​ Formulary
  

• How To Read A Formulary Document​
  

• Recent Formula​ry Changes ​
  

Inclusion and teiring of drugs on the Formulary is determined through a rigorous process in which efficacy, safety and value are considered. Click here for more information on this process. Drugs listed as “PA” (meaning prior authorization) require additional information submitted by your prescriber prior to coverage. Drugs which are not listed on the Formulary are not a covered health service unless Medical Necessity has been determined.

For more information on "PA" and non-formulary drugs see "Prior Authorizations/ Formulary Exceptions Process" section below.

Cost Limitation

Non-compounded prescriptions with a cost of $1,350 or more are subject to review before your pharmacy can fill it for you.  Compounded prescriptions with a cost of $100 or more are subject to review and will be assigned a copay tier before your pharmacy can fill it for you.​

If you are new to GHC-SCW, please fill out the form through the link below and fax/mail it back to Care Management. Our administration team will assist with your transition from the previous insurer.

• Transition of Care

Retail Pharmacy

The GHC-SCW Pharmacy Benefit network also includes many non-GHC retail locations.

For a listing of common national and regional pharmacy chains available in your network, please click her​e. To search for a network pharmacy by zip code, please click here.

Specialty Pharmacy

Some medications can only be dispensed by Specialty Pharmacies to ensure safety, monitoring, and storage requirements are met.

Members with medications that require dispensing through a Specialty Pharmacy Provider must use one of the following:

• GHC-SCW Pharmacies (contact information above)
• Lumicera Health Services (855) 847-3553
• UW Specialty Mail Service Pharmacy (608) 263-1292

Prior Authorizations / Formulary Exceptions Process

Medications listed on Formulary as “PA" (prior authorization) and those not listed on Formulary require submission of additional health information for consideration of coverage.

GHC-SCW uses current clinical practice guidelines, best practice guidelines, peer reviewed publications and/or evidence-based research in the development of its Prior Authorization and Step-Therapy Criteria.  You can click h​ere for more information.

Your prescriber will need to complete a prior authorization request form by visiting https://www.navitus.com/.  Your prescriber will need to select "Prescribers" and login using their NPI number and state of practice. When a drug-specific prior authorization form is not listed, the Formulary Exception Request form may be used. The completed form should be faxed to the GHC-SCW number on the form.

Oncology Drugs (Including Those Requested For Non-Oncology Use) Are Managed By Our Partner MagellanRx

Your prescriber will need to complete an electronic prior authorization request by visiting ih.magellanrx.com. The first time they access the site, they will use the link titled “New Access Request – Provider" and follow the prompts. Once access is granted, the prescriber may search for the requested medication and answer the associated questions. An oncology medication NOT found on this portal should be submitted in the same fashion as a non-oncology medication (see above).​​

Contact

If you have questions regarding your prescription drug benefit you can contact the GHC-SCW Pharmacy Benefits team:

Via GHCMyChart:

• Once logged in to GHCMyChart, click “Messages"

• Select “Ask a Question", then “Member Services Question"

• Select “Pharmacy Benefits Questions" as the topic

• Our team will respond to your question as quickly as possible

Via Phone:

• Monday-Friday, 8 a.m. – 5 p.m.
• (608) 828-4811
• After business hours – contact Navitus Health Solutions for assistance at (866) 333-2757