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, click here for a list of medications that require preauthorization, or log into your member portal or provider portal to view the formulary.