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Sanford Health Plan

Formulary changes and formulary exception process

The Sanford Health Plan formulary can be found through your online provider account at sanfordhealthplan.com/providerlogin. The formulary is located at the bottom of the Member Eligibility section. You may also call the Pharmacy Management team for more information.

How to find a specific drug:

  • Locate the drug in the index list located in the back of the formulary.
  • Find the correlating page number.
  • Find the drug listed on that page number.
  • Notice the tier level indicated, along with any special instructions which will be in abbreviation form. The tier levels and abbreviations are further defined on page 1 of the formulary.

Call the Pharmacy Management team if you have additional questions at (800) 805-7938, option 1. 

Therapeutic Class Formulary Changes
Basal Insulin
(change in effect 9/1/16)
Tresiba added to formulary.
Dermatology
change in effect 6/29/16)
Epiduo Forte added to formulary.
**Note: does not apply to Simplicity, TRUE or ND Medicaid Expansion Plans**
Gastroenterology
(change in effect 3/24/16)
Esomeprazole 40mg (trade name Nexium) added to formulary
**Note: this ONLY applies to the 40mg strength. Quantity limits apply.**
Hepatitis C Therapy
(changes in effect 9/1/16)
Three agents moved to formulary status: Epclusa, Harvoni, and Zepatier.
Therapy class still subject to prior authorization and criteria requirements.
Narcotic Oral Analgesics Hysingla added to formulary.
Ophthalmology
(changes in effect 5/3/16)
Durezol and Ilevro added to formulary.
**Note: does not apply to Simplicity or TRUE Plans**
Pulmonary
(changes in effect 5/3/16)
Dulera added to formulary.

 

Not Covered Covered
Betaseron Avonex, Extavia, Plegridy, Rebif
Incruse Spiriva, Tudorza
Jublia
(change in effect 2/1/16)
ciclopirox olamine nail lacquer (trade name Penlac) topical solution
Synjardy Farxiga, Invokamet, Invokana, Xigduo
**Note: does not apply to Simplicty or TRUE Plans**
Viekira Pak
(change in effect 9/1/16)
Epclusa, Harvoni, Zepatier
Xerese
(change in effect 2/1/16)
acyclovir 5% topical ointment, Denavir 1% ointment

Formulary exception process

Sanford Health Plan occasionally grants formulary exceptions, and will consider an exception under the following circumstances:

  1. The formulary drug causes an adverse reaction in the patient;
  2. The formulary drug is contraindicated for the patient; or
  3. The health care practitioner demonstrates to the health plan that the prescription drug must be dispensed as written to provide maximum medical benefit to the patient.

To request an exception to the formulary, call the Utilization Management Department. You may also complete the online Medication Request Form through your provider mySanfordHealthPlan account.

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