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Partners Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, d...

This handbook tells you about your coverage under PHP Care Complete FIDA-IDD Plan (MedicareMedicaid Plan) from the date you are enrolled with PHP Care...

Annual Notice of Changes to learn about your coverage choices. Key terms and their definitions appear in alphabetical order in the last chapter of th...

This document is a brief summary of the benefits and services covered by PHP Care Complete FIDA-IDD Plan.

If a medically necessary service or benefit is unavailable within PHP Care Complete FIDA-IDD Plan’s provider network, your care coordination team will...

You can ask a friend, relative, your doctor or other provider, or another person to act for you as your “representative“ if you need assistance with a...

Formulary Information and Documents

Prescription Drug Coverage Information

PHP Care Complete FIDA-IDD Plan has a List of Covered Drugs, also known as a Formulary.

When you get a prescription for any of these covered drugs, PHP Care Complete FIDA-IDD Plan will cover the prescription when you go to a network pharmacy. (Some drugs have limits – see Limits on coverage for some drugs below).

PHP Care Complete FIDA-IDD Plan has more than 5,000 retail pharmacies across their nine-county service area. These include Costco, CVS, Duane Reade, King Kullen, Kinney Drugs, Kmart, Pathmark, Price Chopper, Rite Aid, Sam’s, ShopRite, Stop & Shop, Target, TOPS, Waldbaum’s, Walgreens, Wal-Mart, Wegmans plus many “mom & pop” pharmacies.  You can always check our pharmacy directory for a network pharmacy near your home.

PHP has partnered with MedImpact Direct Mail Order to offer participants with a mail-order pharmacy program beginning January 1, 2021!  If you are on any maintenance medications, you can conveniently have up to a three-month supply delivered to your home.  Maintenance medications are used to treat chronic illnesses. Please view the below links for more information on this program, including how to register.

Our Formulary has three tiers and includes drugs covered under Medicare Part D and some prescription and over-the-counter (OTC) drugs covered under your Medicaid benefits.  Each tier has a $0 copay.   You can contact us at Participant Services 1-855-747-5483 or TTY/TDD: 711 for the most recent drug list.

  • Tier 1 covers Generic Drugs that are covered by Medicare Part D.
  • Tier 2 covers Brand Drugs that are covered by Medicare Part D.
  • Tier 3 covers Medicaid-covered drugs and Medicaid-covered Over-the-Counter Drugs (both generic and brand).
Limits on coverage for some drugs

For certain prescription and covered over-the-counter (OTC) drugs, special rules limit how and when we cover them. In general, our rules encourage you to get a drug that works for your medical condition and is safe and effective.

1. Step Therapy: Trying a different drug first

In general, we want you to try lower-cost drugs (that often are as effective) before we cover drugs that cost more. For example, if Drug A and Drug B treat the same medical condition, and Drug A costs less than Drug B, PHP Care Complete FIDA-IDD Plan’s rules may require you to try Drug A first. If Drug A does not work for you, the plan will then cover Drug B. This is called step therapy.

2. Quantity limits

For some drugs, we limit the amount of the drug you can have. For example, the plan might limit:

  • how many refills you can get, or
  • how much of a drug you can get each time you fill your prescription.

3. Prior Authorization

For some drugs, we may ask your prescribing doctor to get prior approval from PHP Care Complete FIDA-IDD Plan before we can have the pharmacy dispense the drug to you.  This is called prior authorization.

Here are some examples of the limits of coverage for some drugs:

  • Digoxin Tabs (Tier 1) requires Prior Authorization
  • Avandia (Tier 2) requires Step Therapy
  • Abilify Tab (Tier 2) requires Quantity Limit of 30 tabs for 30 days;
  • Tamiflu Cap (Tier 2) requires a Quantity Limit of 28 cap over a 180-day period.
  • Acne Medication, Allergy Creams, Vitamins are all Tier 3 covered prescriptions.
What if I’m taking a drug that is not on PHP’s formulary?

If you are a new PHP Care Complete FIDA-IDD Plan participant living in the community and are currently taking a drug that is not on PHP’s formulary but otherwise meets the definition of a Part D drug or a non-Part D drug covered by Medicaid (including formulary drugs that require prior authorization or step therapy), PHP will continue to pay for the drug on a temporary basis (i.e., 90 days). During this period, our Pharmacy Coordinator will consult with you and your Interdisciplinary Team about possible alternatives to the drug. We will also notify you and your authorized representative of your right to file for an exception request to continue taking the drug after the transition period has expired.

If you are a new PHP Care Complete FIDA-IDD Plan participant residing in a long-term care facility such as a nursing home or ICF, you can receive at least a 30 day and up to a 31-day supply of non-formulary drugs that otherwise meet the definition of a Part D drug (including formulary drugs that require prior authorization or step therapy) within the first 90 days of coverage unless a lesser amount is requested.

This document is called the List of Covered Drugs (also known as the Drug List). It tells you which prescription drugs and over-the-counter drugs and ...

It requires patients to try one or more medications specified by the insurance company, typically a generic or lower cost medicine, to treat a health ...

What is the prior authorization process? Prior authorization—sometimes called precertification or prior approval—is a health plan cost-control process...

Provider, Pharmacy, and Dental Directories

To request a copy of a provider directory, please send an email with the name of the requested county and your full mailing address to This email address is being protected from spambots. You need JavaScript enabled to view it..
Can’t find a provider? Call us at 1-855-747-5483 or TTY/TDD: 711 for the most up to date provider listing.

2022 Pharmacy Materials

Participant Rights and Responsibilities
Policy Effective Date: 04/01/2016
  • You have a right to get information in a way that meets your needs
  • We must treat you with respect, fairness, and dignity at all times
  • We must ensure that you get timely access to covered services, items, and drugs
  • We must protect your personal health information
  • We must give you information about PHP Care Complete FIDA-IDD Plan, its network providers, and your covered services
  • Network providers cannot bill you directly
  • You have the right to leave PHP Care Complete FIDA-IDD Plan at any time
  • You have a right to make decisions about your health care
  • You have the right to ask for help
  • You have the right to file a grievance and to ask us to reconsider decisions we have made
  • You have the right to suggest changes
  • You also have responsibilities as a Participant of PHP Care Complete FIDAIDD Plan

Multi-language Interpreter Services

  • English

    We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 1855-747-5483. Someone who speaks English/Language can help you. This is a free service.
  • Spanish

    Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al 1-855-7475483. Alguien que hable español le podrá ayudar. Este es un servicio gratuito.
  • Chinese Mandarin

    我们提供免费的翻译服务,帮助您解答关于健康或药物保险的任何疑 问。如果您需要此翻译服务,请致电1-855-747-5483。我们的中文工作人员很乐意帮助您。 这是一项免费服务。
  • Chinese Cantonese

    您對我們的健康或藥物保險可能存有疑問,為此我們提供免費的翻譯 服務。如需翻譯服務,請致電1-855-747-5483。我們講中文的人員將樂意為您提供幫助。這 是一項免費服務。
  • Tagalog

    Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa 1-855-747-5483. Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo.
  • French

    Nous proposons des services gratuits d'interprétation pour répondre à toutes vos questions relatives à notre régime de santé ou d'assurancemédicaments. Pour accéder au service d'interprétation, il vous suffit de nous appeler au 1-855-747-5483. Un interlocuteur parlant Français pourra vous aider. Ce service est gratuit.
  • Vietnamese

    Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi 1-855-747-5483 sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí .
  • German

    Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-855-747-5483. Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos.
  • Korean

    당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다. 통역 서비스를 이용하려면 전화1-855-747-5483]번으로 문의해 주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다.
  • Russian

    Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по телефону 1-855-747-5483. Вам окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная.
  • Arabic

    اننإ مدقن تامدخ مجرتملا يروفلا ةيناجملا ةباجلإل نع يأ ةلئسأ قلعتت ةحصلاب وأ لودج دلأاةيو انيدل . لوصحلل ىلع مجرتم ،يروف سيل كيلع ىوس لاصتلاا انب ىلع 855-747-5483-1 .موقيس صخش ام ثدحتي ةيبرعلا كتدعاسمب .هذه ةمدخ ةيناجم.
  • Hindi

    हमारे स्वास््य या दवा की योजना के बारे में आपके ककसी भी प्रश्न के जवाब देने के लिए हमारे पास मफ्त दभाषिया सेवाएँ उपिब्ध हैं. एक दभाषिया प्राप्त करने के लिए, बस हमें 1-855-7475483 पर फोन करें. कोई व्यक्तत जो हहन्दी बोिता है आपकी मदद कर सकता है. यह एक मफ्त सेवा है.
  • Italian

    È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero 1-855-747-5483. Un nostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito.
  • Portugués

    Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do número 1855-747-5483. Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito.
  • French Creole

    Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan 1-855-747-5483. Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis.
  • Polish

    Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z pomocy tłumacza znającego język polski, należy zadzwonić pod numer 1-855-747-5483. Ta usługa jest bezpłatna.
  • Japanese

    当社の健康 健康保険と薬品 処方薬プランに関するご質問にお答えするため に、無料の通訳サービスがありますございます。通訳をご用命になるには、1-855-7475483にお電話ください。日本語を話す人 者 が支援いたします。これは無料のサー ビスです。

How can we assist you?

Contact Partners Health Plan for current member assistance, to learn more about becoming a PHP member, or for general questions and inquiries.

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