Outpatient Prescription Drugs

Sharp Health Plan members may obtain covered outpatient prescription drugs from Sharp Health Plan contracted pharmacies, located throughout San Diego and southern Riverside counties. The Drug List provides detailed information on medications covered by Sharp Health Plan. Members can use our Pharmacy Search to find a Sharp Health Plan pharmacy in a convenient location. Members also have the option of using Wellpartner mail order pharmacy services for maintenance medications.

Prior authorization

Some medications require prior authorization, which means the prescribing physician must complete a Prior Authorization Request form and submit it with relevant medical information to Sharp Health Plan. Sharp Health Plan will evaluate the information submitted and make a decision based on established clinical criteria for that drug.

Sharp Health Plan does not cover a brand-name drug when a generic is available, unless there is a medical reason why the generic cannot be used. The Food and Drug Administration (FDA) applies rigorous standards for identity, strength, quality, purity and potency before approving a generic drug. Generics are required to have the same active ingredient, strength, dosage form and route of administration as their brand name equivalents. If a patient cannot use the generic version of a medication due to an adverse reaction, physicians are asked to report the finding to the FDA using the MedWatch report form. Providers can then submit a copy of the completed MedWatch form and a Prior Authorization Request form to Sharp Health Plan to request coverage for the brand name drug.

At Sharp Health Plan, we make utilization management decisions based only on appropriateness of care and service (after confirming health coverage). The doctors, nurses, pharmacists and pharmacy technicians who conduct utilization reviews are not rewarded for denials of care or service, and there are no incentives for utilization management decision-makers that encourage decisions resulting in underutilization of health care services.

Specialty drugs

Certain specialty medications are provided exclusively by Diplomat Specialty Pharmacy. Specialty medications are drugs that may require specialized delivery and administration on an ongoing basis. They are often for chronic conditions and involve complex care issues that need to be managed. Examples include Xeloda, Temodar, Sensipar, and Zortress.

Pharmacy benefit resources

The following information is provided to assist physicians who prescribe outpatient prescription drugs for Sharp Health Plan members. Follow the links below for more information about the outpatient prescription drug benefits available through Sharp Health Plan.

We’re here for you

If you can’t find what you are looking for, please don’t hesitate to pick up the phone and call our Network Development / Provider Support Department at (619) 228-2396, or send an e-mail via our Contact Us Form.