Pharmacy & Formulary

Prior Authorization Requests

SFHP Pharmacy Prior Authorization Requests can be submitted by providers one of three different ways:

  1. Fax: Download a Prior Authorization Request Form and fax to 1(855) 811-9331 for both standard and urgent requests. Urgent requests should be clearly labeled “URGENT” at the top of the prior authorization request form.
  2. Call: Pharmacy Benefits Manager (PBM) PerformRx at 1(888) 989-0091 to submit a verbal request.
  3. Online: Submit using the Online Pharmacy Prior Authorization Request Form.

Effective January 1, 2015

The new Prescription Drug Prior Authorization Request Form is required for non-Medicare plans per DMHC regulations (Section 1300.67.241). *Please note the new form.

Prior Authorization Criteria

SFHP uses prior authorization criteria to evaluate prior authorization requests. These criteria are based on clinical monographs and national guidelines, and have been approved by the SFHP Pharmacy Therapeutics (P&T) Committee. Drug-specific criteria can be found by selecting the drug in the searchable formulary and clicking “Clinical Criteria”.

SFHP also uses general criteria for non-formulary medications without specific criteria, and for restrictions such as age and quantity limits. The general criteria are also linked on the searchable drug formulary page for each line of business. To view, click here.

Request for Formulary Modification

San Francisco Health Plan holds quarterly Pharmacy and Therapeutic (P&T) Meetings with committee members from the community to discuss any clinical updates or changes. Suggestions for formulary modification will be addressed. If you have a formulary suggestion, please fill out the Formulary Modification Request form and fax it to 1(415) 547-7819. Your recommendation will be addressed at the subsequent (P&T) meeting.