Employee Health Plan Prescription Drug Benefit

The appropriate, cost-efficient use of pharmaceutical therapies can be an effective strategy for improving your health. Cleveland Clinic’s EHP Prescription Drug Benefit provides members with medications based on each drug’s effectiveness, safety and value.   

Cleveland Clinic Pharmacy Information

EHP members receive a lower percentage co-insurance for their prescriptions by using Cleveland Clinic Pharmacies or the Specialty/Home Delivery Pharmacy. The deductible will be waived when filling generic medications at the Cleveland Clinic pharmacies. Cleveland Clinic pharmacies prefer a 90-day supply on maintenance medications and have access to the pharmacy hotline for questions and pharmacist consultation services. A listing of the Cleveland Clinic Pharmacies is available within the 2023 Main Campus Resident and Fellows Summary Plan Description.
EHP offers a home delivery service through Cleveland Clinic. To get started, please visit the Cleveland Clinic Home Delivery Pharmacy MyRefills website where you can set up your account, change your billing information and shipping address, or check on the status of your order.  Please call 216.448.4200 for questions or additional information.

Specialty Medication Copay Program

Cleveland Clinic Employee Health Plan (EHP) members (EHP and EHP Plus): Do you or your dependents have prescriptions for specialty medications? If so, good news, EHP and CVS Caremark are collaborating with PrudentRx to offer the new copay program for all health plan members who use particular specialty medications. This program will be available at no cost to plan members and replaces the current internal EHP specialty drug copay card assistance program for most specialty medications.

Members who enroll in the PrudentRx program will not have a copay for their specialty medication prescriptions. If members do not enroll, they may be subject to 30% co-insurance costs for specialty medications after the annual prescription benefit deductible has been satisfied.

Next steps

To get started, you will be informed multiple ways in how to enroll in the program such direct contact with the pharmacy when picking up the medication, will receive a letter from EHP Pharmacy Management on specialty medications that have precertification approvals. Lastly, PrudentRx will reach out directly to members if they have seen a paid claim in the past at that 30% coinsurance cost.

Please see the PrudentRx Specialty Drug List and EHP Specialty Drug List to verify if you are eligible to enroll in Prudent RX for your specialty medications. If you do not use a specialty medication included in the PrudentRx program, you will not receive a letter, and no action will be required. If you have questions about the PrudentRx specialty medication copay program, contact PrudentRx at 1.800.578.4403.  

Prior Authorization/Formulary Exception

Prior authorization is necessary for coverage of certain medications which are listed in the Drug Formulary. The medications on the list may change throughout the year due to FDA approvals of new drugs or new indications are established for previously approved drugs. A  Prior Authorization/Formulary Exception Form  must be completed or sufficient documentation must be submitted before a case will be reviewed.

Disclaimer:  All requests must meet the clinical criteria approved by the Pharmacy and Therapeutics (P&T) Committee before approval is granted. In some cases, approvals will be given a limited authorization date. If a limited authorization is given both the member and the physician will receive documentation on when this authorization will expire. Most requests will be processed within 1-2 business days from the time of receipt. A response will be faxed to the requesting physician, and the member will be informed of the request and the decision via mail. 

Statin Medications for Primary Prevention of Cardiovascular Disease

As of January 1st, 2018, under the provisions of the Affordable Care Act mandate regarding cardiovascular disease preventive health services, generic formulary low to moderate dose statins will be covered under the EHP Prescription Drug Benefit at no member out-of-pocket expense within specific coverage guidelines. To begin this process, please have the prescribing provider submit a Statin Formulary Exception Questionnaire to the Employee Health Plan Pharmacy Management Department. All requests must meet the clinical criteria approved by the EHP Pharmacy and Therapeutics (P&T) Committee before approval is granted. Additional information can be found in the EHP Drug Formulary Book (link above).

Breast Cancer Prevention Coverage

Under the provisions of the Affordable Care Act mandate regarding breast cancer preventive health services, generic raloxifene and tamoxifen will be covered under the EHP Prescription Drug Benefit at no out-of-pocket expense only for female members 35 years of age or older when accompanied by a valid prescription from the member's healthcare provider.

Two medications used in the prevention of breast cancer, generic anastrozole and generic exemestane, will also be covered at no member cost. If the member's individual medical condition meets the criteria set forth by the United States Preventive Services Task Force. Members or providers can obtain the Aromatase Inhibitor for Breast Cancer Risk Reduction Formulary Exception form here. Use this form to request coverage of these medications at no member cost.