Pharmacy and prescription drugs

  • Drug list
  • Mail order
  • Medication therapy management program
  • Drug coverage determinations
  • Exceptions, limitations & coverage determinations
  • Part D transition program
  • Quality assurance policy
Search or view the drug list

How to use the Online Drug List

To search for a specific drug, type the name of the drug into the search box. A drop-down list will appear. Select the desired drug and click the red "Add to List" button. A table with your drug's information will then appear.


Search the Online Drug List


How to use the Drug List PDF

To find a specific drug in the Drug List PDF, press "Ctrl" and "F" on a Windows computer, or press "command" and "F" on a Mac. A search box will appear in the top right corner of your browser. Enter the name of the drug you are looking for.


View the drug list View the drug list in Spanish

 

View the 2023 drug list View the 2023 drug list in Spanish


Drug list information

Sharp Direct Advantage provides Medicare prescription drug coverage under an approved formulary, or drug list. The formulary is a list of covered drugs provided by Sharp Direct Advantage. The formulary drugs are selected because they are believed to be a necessary part of a quality treatment program.

Sharp Direct Advantage covers both brand name and generic drugs. Generic drugs have the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs. The formulary is updated regularly. Please review your prescriptions to ensure they are covered.

Our drug list is updated on a monthly basis. For more recent information or an updated list of drugs, please contact our Customer Care team by dialing our toll-free number: 1-855-562-8853 (TTY/TDD: 711). Our team is available 7 am to 8 pm, seven days a week.


Mail order

Why CVS Caremark?

With CVS Caremark, you can get your prescriptions delivered to your address of choice. You can also track your orders, view your prescription history and more — by phone, via their website or through an easy-to-use mobile app.


How do I transfer my prescriptions to CVS Caremark?

If you want to receive your prescriptions through mail order, then you will have to create an account with CVS Caremark, and add your payment information. You can do that by visiting caremark.com or calling our 24-hour prescription helpline at 1-855-222-3183.


What should I do if I’m not currently using mail order, but want to sign up?

Please visit caremark.com to create an account or call our 24-hour prescription helpline at 1-855-222-3183 for assistance.


What is the medication therapy management program?

The Sharp Direct Advantage Medication Therapy Management (MTM) Program helps you get the most out of your medications by:

  • Preventing or reducing drug-related risks
  • Supporting good lifestyle habits
  • Providing information for safe medication disposal options


Who qualifies for the program?

You will be enrolled in the Sharp Direct Advantage MTM Program if you meet one of the following:

  1. Have coverage limitation(s) in place for medication(s) with a high risk for dependence and/or abuse, or
  2. Meet the following criteria:
    • You have three or more of these conditions:
      • Chronic heart failure (CHF)
      • Depression
      • Diabetes
      • Dyslipidemia
      • Hypertension
      • Respiratory Disease – Asthma
      • Respiratory Disease – Chronic Obstructive Pulmonary Disease (COPD)
      • Chronic alcohol & drug dependence
      • HIV/AIDS
    • You take eight or more maintenance medications covered by your plan
    • You are likely to spend more than $4,696 in prescription drug costs in 2022

Your participation in the MTM Program is voluntary and does not affect your coverage. This is not a plan benefit and is open only to those who qualify. There is no extra cost to you for the MTM Program.


How will I know if I qualify for the program?

If you qualify, we will mail you a letter. You may also receive a call to set up your one-on-one medication review.


What services are included in the program?

In the MTM Program, you will receive the following services from a health care provider:

  • Comprehensive medication review
  • Targeted medication review


What is a comprehensive medication review?

The comprehensive medication review is completed with a health care provider in person or over the phone. This review is a discussion that includes all your medications:

  • Prescriptions
  • Over-the-counter (OTC)
  • Herbal therapies
  • Dietary supplements

This review usually takes 20 minutes or less to complete. During the review, you may ask any questions about your medications or health conditions. The health care provider may offer ways to help you manage your health and get the most out of your medications. If more information is needed, the health care provider may contact your prescriber.


At the end of the review, the health care provider will provide you with a summary of what you discussed. The summary will include the following:

  • Recommended To-Do List. Your plan may include suggestions for you and your prescriber to discuss during your next visit
  • Personal Medication List. This is a list of all the medications discussed during your review. You can keep this list and share it with your prescribers and/or caregivers


Who will contact me about the review?

You may receive a call from a pharmacy where you recently filled one or more of your prescriptions. You can choose to complete the review in person or over the phone.

A health care provider may also call you to complete your review over the phone. When they call, you can schedule your review at a time that is best for you.


Why is this review important?

Different prescribers may write prescriptions for you without knowing all the medications you take. For that reason, the MTM Program health care provider will:

  • Review all your medications
  • Discuss how your medications may affect each other
  • Identify any side effects from your medications
  • Help you reduce your prescription drug costs


How do I benefit from talking with a health care provider?

By completing the medication review with a health care provider, you will:

  • Understand how to safely take your medications
  • Get answers to any questions you may have about your medications or health conditions
  • Review ways to help you save money on your drug costs
  • Receive a Personal Medication List and Recommended To-Do List to keep and share with your prescribers and/or caregivers


What is a targeted medication review?

The targeted medication review is completed by a health care provider who reviews your medications at least once every three months. With this review, we mail, fax, or call your prescriber with suggestions about prescription drugs that may be safer or work better for you. As always, your prescriber will decide whether to consider our suggestions. Your prescription drugs will not change unless you and your prescriber decide to change them. We may also contact you by mail or phone with suggestions about your medications.


How can I get more information about the MTM Program?

Please contact us if you would like more information about the Sharp Direct Advantage MTM Program or if you do not want to participate. Our number is 1-844-635-3406, 24 hours a day, 7 days a week. (TTY users, call 711.)


How do I safely dispose of medications I don’t need?

The Sharp Direct Advantage MTM Program is dedicated to providing you with information about safe medication disposal. Medications that are safe for you may not be safe for someone else. Unneeded medications should be disposed of as soon as possible. You can discard your unneeded medications through a local safe disposal program or at home for some medications.

  • Locating a community safe drug disposal site

    A drug take back site is the best way to safely dispose of medications. To find drug take back sites near you, visit the website below and enter your location:


    https://apps2.deadiversion.usdoj.gov/pubdispsearch/spring/main?execution=e2s1

    Some pharmacies and police stations offer on-site drop-off boxes, mail-back programs, and other ways for safe disposal. Call your pharmacy or local police department (non-emergency number) for disposal options near you.

  • Mailing medications to accepting drug disposal sites

    Medications may be mailed to authorized sites using approved packages. Information on mail-back sites can be found at www.deatakeback.com.

  • Safe at-home medication disposal

    You can safely dispose of many medications through the trash or by flushing them down the toilet. Visit the website of the U.S. Department of Health and Human Services to learn more about safe at-home disposal.


    Follow these steps for medication disposal in the trash:
    1. Remove medication labels to protect your personal information
    2. Mix medications with undesirable substances, such as dirt or used coffee grounds
    3. Place mixture in a sealed container, such as an empty margarine tub


Exceptions & prior authorization

Generally, we must make our decision within 72 hours of getting your prescriber’s or prescribing doctor’s supporting statement. You can request an expedited (fast) request if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get your prescriber’s or prescribing doctor’s supporting statement.


Exceptions are also called coverage determinations. Members can request an exception to the Sharp Direct Advantage cost-sharing structure, to the formulary, or to obtain a formulary drug that is subject to a utilization management restriction (e.g., step therapy, prior authorization, quantity limit) that you or your prescriber believes should not apply. Once an exception is approved, it is approved for the remainder of the plan year. This means we cannot require a member to request approval for a refill or new prescription to continue using a Part D prescription drug already approved under the exceptions process, for the remainder of the plan year. In order to keep the exception in place for the whole year, the member must remain enrolled in Sharp Direct Advantage, the member’s physician or other prescriber must continue to prescribe the drug and the drug must continue to be safe for treating the member’s condition.


When an exception request is approved, we will give the member a written approval letter and clearly state the date that coverage will end.


Sharp Direct Advantage may immediately remove a brand name drug on our Drug List if we are replacing it with a newly approved generic version of the same drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a higher cost-sharing tier or add new restrictions. We may not tell you in advance before we make that change—even if you are currently taking the brand name drug.


Sharp Direct Advantage may make other changes once the year has started that affect drugs you are taking. For instance, we might add a generic drug that is not new to the market to replace a brand name drug or change the cost-sharing tier or add new restrictions to the brand name drug. We also might make changes based on FDA boxed warnings or new clinical guidelines recognized by Medicare. We will give written notice to affected enrollees at least 30 days in advance of the change becoming effective. If we are unable to give a 30-day advance notice, we will provide a 30-day supply of the drug impacted by the change and give written notice at the time of your refill.


Please contact us with any questions.



Download the Medicare Prescription Drug Coverage Determination Request Form (individual and group). For the best results, the form should be filled out printed from your web browser. You cannot use this form for Medicare non-covered drugs:

  • Fertility drugs
  • Drugs prescribed for weight loss, weight gain or hair growth
  • Over-the-counter drugs
  • Prescription vitamins (except prenatal vitamins and fluoride preparations)

You can also fill out an online Medicare prescription drug coverage determination form.


Formulary exceptions

You, your prescriber, or your Authorized Representative may request a formulary exception by faxing or mailing a completed Medicare Prescription Drug Coverage Determination Form to us.

Sharp Direct Advantage uses various tools to ensure the quality of the health care it provides. These tools also extend to providing prescription drug coverage. These tools include, but are not limited to: prior authorization criteria, clinical edits and quantity limits.


Age limits

Age Limits: Some drugs require a prior authorization if your age does not meet the manufacturer, FDA, or clinical recommendations.


Quantity limits

Quantity Limits: For certain drugs, Sharp Direct Advantage limits the amount of the drug we will cover per prescription or for a defined period of time.


Step therapy

In some cases, Sharp Direct Advantage requires you to first try one drug before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.

Read the current step therapy requirements


Prior authorization

We require you to get prior authorization for certain drugs. You may need prior authorization for drugs that are on the formulary or drugs that are not on the formulary and were approved for coverage through our exceptions process. This means that you will need to get approval before you fill your prescriptions. If you don’t get approval, the drug may not be covered by Sharp Direct Advantage.

Read the requirements


Opioid safety program

Sharp Health Plan is required to comply with the Centers for Medicare & Medicaid Services requirements to prevent opioid overuse and protect patient safety. As a result, we have enhanced our opioid safety program to include various safety edits to prevent prescription opioid overuse in new opioid users, chronic opioid users, and those with potentially unsafe concurrent medication use. Below is an overview of our opioid safety edits for all Sharp Direct Advantage members.

Opioid cumulative dose safety edit (updates effective 1/1/2021)

The opioid cumulative dose safety edit will trigger and deny the member’s prescription when the member’s cumulative morphine milligram equivalents (MME) per day across their opioid prescription(s) exceeds the safety threshold at the pharmacy. The edit will have the following features:

  1. Soft edit: For claims from three or more prescribers that meet or exceed 90 MME, pharmacies will be notified to verify dosing with the prescriber and to ensure care coordination. Once the prescriber confirms clinical appropriateness, the pharmacy can use an override code to indicate the prescriber has been consulted and continue to dispense the medication.
  2. Hard edit: For claims from three or more prescribers that meet or exceed 200 MME, pharmacies will be notified that a coverage determination is required. The prescriber will need to request a coverage determination to confirm dosing. Pharmacies are unable to use an override code.

Opioid and benzodiazepine concurrent use safety edit

The opioid and benzodiazepine concurrent use safety edit will trigger and deny the member’s prescription when the member has any overlap in day supply for opioids and benzodiazepines at the pharmacy. The edit will have the following feature:

  1. Soft edit: Checks the member's prescription history for interactions between opioids and benzodiazepines. Pharmacies will be notified to verify with the prescriber the appropriateness of using both medications at the same time. Once the prescriber confirms clinical appropriateness, the pharmacy can use an override code to indicate the prescriber has been consulted and continue to dispense the medication.

Opioid naïve day supply limitation safety edit

The opioid naïve day supply limitation safety edit will trigger and deny the member’s prescription when the member’s initial opioid prescription fill for the treatment of acute pain exceeds 7-day supply. Both short-acting and long-acting opioids, except buprenorphine for medication-assisted treatment (MAT) will be included in this safety edit. The edit will have the following feature:

  1. Hard edit: For patients without an opioid prescription filled in the last 108 days, claims for an opioid prescription will be limited to a 7-day supply for the treatment of acute pain. For claims exceeding a 7-day supply, pharmacies will be notified that a coverage determination is required. The prescriber will need to request a coverage determination to confirm dosing. Pharmacies are unable to use an override code.

Duplicative long-acting opioid therapy safety edit

The duplicative long-acting opioid therapy safety edit will trigger and deny the member’s prescription when the member has any overlap in day supply for two or more long-acting opioid medications. The edit will have the following feature:

  1. Soft edit: If two or more prescriptions for long-acting opioids overlap in day supply, pharmacies will be notified to verify with the prescriber the appropriateness of using both medications at the same time. Once the prescriber confirms clinical appropriateness, the pharmacy can use an override code to indicate the prescriber has been consulted and continue to dispense the medication.

Opioid and buprenorphine concurrent use safety edit

The opioid and buprenorphine concurrent use safety edit will deny the member’s opioid prescription claim at the pharmacy when the member is concurrently using any buprenorphine-containing product for medication assisted treatment (MAT).

  1. Soft edit: Once the prescriber confirms clinical appropriateness, the pharmacy can use an override code to indicate the prescriber has been consulted and continue to dispense the medication.

Members in long-term care facilities, with sickle cell disease, enrolled in hospice, in palliative care, or being treated for cancer will be exempted from opioid edits.

For all opioid safety edits, Sharp Health Plan will apply the appropriate drug utilization review process to ensure access is maintained for needed medications, and the dispensing pharmacist will be given the opportunity to override the rejection for soft edit.


Generic substitution

When there is a generic version of a brand-name drug available, our network pharmacies will automatically give you the generic version, unless your doctor has told us that you must take the brand-name drug. If the brand-name drug is approved, you may be responsible for a higher co-pay and/or the difference in cost between the brand and generic medications. Prior authorization criteria‚ clinical step edits and quantity limits may also apply.


Part D transition program information

Prescription drug transition process
What to do if your current prescription drugs are not on the formulary or are restricted in some way.

New members
As a new member of a Sharp Direct Advantage plan, insured through Sharp Health Plan, you may currently be taking drugs that are not on our formulary or are on our formulary but coverage is restricted in some way.

Under certain circumstances, you may be able to get a temporary supply of your prescription drug. This will give you and your doctor time to change to another drug or request an exception and ask to cover the drug or remove restrictions from the drug. If the exception is approved, you will be able to obtain the drug you are taking for the specified period of time.

While you are talking with your doctor to determine your course of action, you are eligible to receive an initial 30-day supply of the drug anytime during the first 90 days you are a member of our plan. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30-day supply. The prescription must be filled at a network pharmacy.

After your first 30-day transition supply, we may not continue to pay for these drugs under the transition policy. You are reminded to discuss with your doctor appropriate alternative therapies on our formulary and if there are none, you or your doctor can request an exception.

If you are a resident of a long-term care facility, we will cover a temporary supply of your drug during the first 90 days of your membership in our plan. The total supply will be for a maximum of a 34-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 34-day supply. Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.

If you reside in a long-term care facility and need a drug that is not on our formulary or coverage is restricted in some way, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for less than 31 days) while you pursue a formulary exception.

There may be unplanned transitions such as hospital discharges or level of care changes (i.e., in the week before a long-term care discharge) that occur after the first 90 days that you are enrolled as a member of our plan. If you are prescribed a drug that is not on our formulary or coverage is restricted in some way, you may request a one-time emergency supply of up to 31 days (unless you have a prescription written for less than 31 days) to allow you time to discuss alternative treatment with your doctor or to pursue an exception. This is in addition to the above long-term care transition supply.

Continuing members
As a continuing member in the plan, you receive an Annual Notice of Change (ANOC). We will tell you about any change in the coverage for your drug for next year.

If a drug you are taking will be removed from the formulary or restricted in some way for next year, work with your doctor to find a different drug that we cover. If there is no alternative, you or your doctor can request a formulary exception.

If you have not discussed with your doctor to switch to an alternative formulary medication or pursued a formulary exception, you are eligible to receive a temporary 30-day supply of your drug as of January 1 of the next benefit year. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of 30-day supply. The prescription must be filled at a network pharmacy. After your 30-day transition supply, we may not continue to pay for your drug under the transition policy. You are reminded to work with your doctor to find a different drug that we cover or you or your doctor can request an exception.

There may be unplanned transitions such as hospital discharges or level of care changes (i.e., in the week before a long-term care discharge) that can occur anytime. If you are prescribed a drug that is not on our formulary or coverage is restricted in some way, you are required to use the Plan's exception process. You may request a one-time emergency supply of up to 31 days (unless you have a prescription written for less than 31 days) to allow you time to discuss alternative treatment with your doctor or to pursue a formulary exception.

If you are a resident of a long-term care facility, we will cover up to a temporary 31-day supply (unless you have a prescription written for less than 31 days). If you have any questions about our transition policy or need help asking for a formulary exception, please contact Sharp Health Plan customer care.


Quality assurance policy and procedures

Sharp Health Plan’s Medicare Part D Quality Assurance policies are designed to ensure the safe and appropriate use of prescription drugs. Sharp Health Plan utilizes drug utilization review (DUR) systems and controls to improve the quality of care provided to our members by identifying patterns of inappropriate or medically unnecessary drug utilization. DUR controls are used to meet the following goals:

  • Reduce medication errors
  • Reduce adverse drug interactions
  • Improve medication use
  • Reduce costs when medically appropriate

Prescription drug claims processing, DUR control implementation, and pharmacy network management is performed by Sharp Health’s pharmacy benefit manager. The pharmacy benefit manager has the ability to control which messages are sent to the pharmacy and also to deny claims when a contraindication occurs.  

Several levels of concurrent DUR controls are used during the processing of prescription drug claims at the pharmacy. Level One and Level Two controls are safety controls and include but are not limited to the following:

  • Drug-drug interaction
  • High or low dosage
  • Ingredient duplication
  • Drug-age interaction
  • Pregnancy
  • Gender
  • Therapeutic duplication
  • Quantity limits
  • Late refill or underuse
  • Refill too soon or overuse

Sharp Health Plan also uses the following safety edits to ensure the safe and appropriate use of opioids:

  • Opioid prescriptions for greater than a 7-day supply in members new to opioid therapy
  • Care coordination safety edit for members receiving greater than 90 morphine milligram equivalent (MME) from 4 or more prescribers
  • Members received greater than 200 MME from 4 or more prescribers
  • Duplicative long-acting opioid therapy
  • Concurrent opioid and benzodiazepine therapy
  • Concurrent opioid and buprenorphine for medication assisted treatment (MAT) therapy

In addition to concurrent DUR controls, Sharp Health Plan performs retrospective DUR. Retrospective DUR activities include but are not limited to the following:

  • Medication Therapy Management Program
  • Review of CMS-generated reports (e.g. Outlier Prescribers of Scheduled II Controlled Substances, CMS/MEDIC Pharmacy Risk Assessment, CMS Quarterly Drug Trend Analysis, etc.)
  • Review of plan-generated reports to identify over- and under-utilization

For additional information regarding your plan benefits, please contact: Sharp Health Plan at 1-855-562-8853 (TTY/TDD: 711). Our team is available 7 am to 8 pm, seven days a week.


Over-the-counter (OTC) benefit

Save money on common medications and health care items with CVS. View the catalog and order online.

Sharp Direct Advantage is offered by Sharp Health Plan. Sharp Health Plan is an HMO with a Medicare contract. Enrollment with Sharp Health Plan depends on contract renewal. Read the full disclaimer.

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