Pharmacy

Delaware First Health covers most prescription medications. The Prescription Drug List (PDL) lists the available medications and any limitations.  Your doctor will help you with prescriptions that need authorization.  Delaware First Health covers certain Prescription Drug List (PDL) over-the-counter medications with a prescription from a Delaware First Health provider. Delaware First Health also offers an Enhanced Over-The-Counter benefit.

Which Drugs are covered?

The Preferred Drug List (PDL) is a list of drugs covered by Delaware First Health. Delaware First Health works with the State of Delaware to ensure that medications used to treat a variety of conditions and diseases are covered. The PDL applies to drugs you receive at retail or mail order pharmacies. Delaware First Health's PDL is continually evaluated by Pharmacy and Therapeutics Committees to promote the appropriate and cost-effective use of medications. 

To view the Preferred Drug List, visit the Handbook and Forms page.

Specialty Drugs

A specialty drug is a prescription drug that requires special handling, administration, or monitoring. These are usually ordered through a specialty pharmacy.

How Do I Get Medications?

You can have your prescriptions filled at a pharmacy in the Delaware First Health network. At the pharmacy, you will need to give the pharmacist your prescription and your Delaware First Health ID Card. If you need help finding a pharmacy near you, call Delaware First Health at 1-833-236-1887 (TTY: 711).

Can I Get a Prescription with More Than a 34-day Supply?

As a general rule, Delaware First Health members are allowed 34-day supply with the exception of birth control and certain maintenance medications. Delaware First Health members are allowed a 90-day supply of birth control and maintenance medications through a Retail pharmacy that offers extended day supplies or through the mail order pharmacy. To order maintenance medications through mail order, call 1-888-624-1139, Option 2.  Or use the mail order form found here: 90-day Mail Order Form.  

Where Can I Get My Prescription Filled?

To find a pharmacy that is in the Delaware First Health network, you can use the Find a Provider tool. Type in your city or zip code. Then click Update. Choose Other and type the name of your pharmacy. You can also select the pharmacy type in the Select Specialty area. Only those pharmacies in the Delaware First Health network are listed.

Prior Authorization

Some state-approved medications may require a Prior Authorization.  If so, your physician will submit a Prior Authorization request to Pharmacy Services.  Pharmacy Services will review the request within 24 hours.  If approved, you will be notified by your physician that your request has been approved and to go to a network pharmacy with your script.

If the Prior Authorization is not approved, Pharmacy Services will notify the physician that submitted the Prior Authorization and mail you a letter.  Speak to your physician regarding potential alternatives.

If you need assistance from Delaware First Health, call 1-833-236-1887.

Federal law allows dispensing of a 72-hour supply of medication in an emergency situation. Delaware First Health will allow a 72-hour supply of medication to a member awaiting a PA determination, unless PA criteria does not allow. The purpose is to avoid interruption of current therapy or delay in the initiation of therapy. All participating pharmacies are authorized to provide a 72-hour supply of medication and will be reimbursed for the ingredient cost and dispensing fee of the 72-hour supply of medication (unless PA criteria does not allow), whether or not the PA request is ultimately approved or denied. 72- hour emergency supply fills are limited to one emergency fill, per drug, during a 60 calendar day period. The pharmacy will contact the Pharmacy Services for a prescription override to submit the 72 hour medication. The Pharmacy Services help desk for pharmacies is available 24 hours a day, 7 days a week.

Pharmacy Copayments

Some Delaware First Health members will have a copay for prescription medications, based on the cost of the medication:

$10.00 or less - $0.50

$10.01 to $25.00 - $1.00

$25.01 to $50.00 - $2.00

$50.01 or more - $3.00

The most a member will pay for prescription copays, in a calendar month, is $15.  Once the member reaches the $15 of accumulated prescription copays in a calendar month, copays are waived for the remainder of the calendar month in which the member reaches the $15 maximum.  The copays and the $15 copay maximum will start over on the next calendar month.

Members and services exempt for copays:

1. Children under the age of 21
2. Pregnant women, including the post-partum period (90 days)
3. Chronic Renal Disease Program (CRDP) members
4. Long-term care nursing facility group or the acute care hospital group
5. Family planning services and supplies
6. Hospice services
7. Naloxone opioid overdose rescue medications
8. Medication-Assisted Treatment (MAT) used for Opioid Use Disorder

Medical Necessity Guidelines

See Clinical and Payment Policies page for more information.

Enhanced Over-The-Counter Items (OTC)

Members are eligible for additional Over-The-Counter items up to a calendar, quarterly maximum benefit of $30 per Household.  These items do not require a prescription.  A list of available OTC items can be found here:  Pharmacy Over the Counter Brochure (PDF) or Pharmacy Over the Counter Brochure (Spanish PDF). Call 1-888-628-2770.

• Order from a customer service representative
• Use the automated phone option
• Online