Pharmacy Services

Valley Health Plan (VHP) covers all drugs that are listed in the VHP Formulary that is maintained by the VHP Pharmacy and Therapeutics Committee. VHP pharmacy benefit is managed by Navitus Health Solution. Navitus Customer Care is available 24/7 and can be reached Seca ti t 1on - 1-333-2757. Medically necessary non-formulary drugs may be covered by filling out an “Exception to Coverage (ETC)” form. (See Section 14 Forms & attachment). Forms can also be obtained using your NPI number through www.navitus.com or call Navitus at 1-866-333-2757. ETC form will be processed within 5 working days. Urgent ETC form will be processed within 72 hours. ETC form should be faxed to 920-735-5350. All prescriptions must be filled at a VHP network pharmacy. In case of an emergency where a VHP network pharmacy is not available, members may fill the prescription at an out of network pharmacy. If a Member uses an out of network pharmacy, the Member must pay the pharmacy directly and submit receipts for reimbursement to:

Navitus Health Solutions

Operations Division - Claims P.O. Box 999 Appleton, WI 54912-0999 Dentist can prescribe only for antibiotics and pain medications. Optometrist can prescribe only for ophthalmic agents.

Drug Formulary

To obtain a copy of the Drug Formulary call Provider Relations at (408) 885-2221.

VHP Pharmacy Benefits and Authorization

Valley Health Plan uses a Formulary developed by Valley Health Plan Pharmacy and Therapeutics (P&T) Committee. The primary purpose of the Formulary is to promote efficacious and cost-effective pharmacotherapy. In most instances, medications will be dispensed by the pharmacy without the need for any intervention. However, in some instances the pharmacy will require additional information from the prescribing physician in order to dispense the medication and receive payment. When prior authorization is required for a drug, please contact Navitus at the above listed numbers.

Section 10 Page 35 of 68

VHP NETWORK PHARMACIES

• Safeway Pharmacies o All U.S locations. For a list of locations visit www.safeway.com • Walgreens Pharmacies o All U.S locations. For a list of locations visit www.walgreens.com • Gardner Family Health Network St. James Health Center 55 E. Julian Street, San Jose Tel: 408-918-2600 • Gardner Family Health Network South County Health Center Pharmacy 700 W. 6th Street, Suite F Gilroy, CA 95020 Tel: 408-848-9400 • Palo Alto Medical Foundation (PAMF) Palo Alto Center Pharmacy 795 El Camino Real Lower Level A, Lee Building Palo Alto, CA 94301 Tel: 650-853-6066 • Palo Alto Medical Foundation (PAMF) Mountain View Center Pharmacy 701 E. El Camino Real Mountain View, CA 94040 Tel: 650-934-7699 • Leiter’s Compounding Pharmacy 1700 Park Avenue, Suite 30 San Jose, CA 95126 Tel:408-292-6772 • Valley Specialty Center 751 S. Bascom Ave., San Jose

Tel: 408-885-2310 • Valley Health Center Bascom 750 S. Bascom Avenue, San Jose

Tel: 408-885-2320 • Valley Health Center East Valley 1993 McKee Road, San Jose

Tel: 408-254-6340 • Valley Health Center Gilroy 7475 Camino Arroyo, Gilroy

Tel: 408-852-2297 • Valley Health Center Lenzen 976 Lenzen Avenue

San Jose, CA 95126

Refill line: 408-792-5169 • Valley Health Center Milpitas 143 North Main Street

Tel: 408-957-0919 • Valley Health Center Moorpark 2400 Moorpark Avenue, San Jose

Tel: 408-885-7675 • Valley Health Center Sunnyvale 660 S. Fair Oaks Avenue, Sunnyvale

Tel: 408.992.4830 • Valley Health Center Tully 500 Tully Road, San Jose

Tel: 408-817-1360