Forms & FAQs

If PEHP is your secondary carrier, you must fill your prescriptions through your primary carrier. PEHP will coordinate eligible copays and unpaid claims as long as they meet PEHP’s benefit, coverage, preauthorization, and quantity rules.

Submit an original itemized receipt (not a pharmacy printout) and a claim form to Express Scripts. PEHP will reimburse up to our usual and customary rate minus your required copay.

• Drug quantities, dosage levels and length or therapy may be limited to the recommendations of the drug manufacturer, FDA, clinical guidelines, or other safety and efficacy concerns.
• PEHP may classify a FDA approved generic medication as non-preferred or not covered.
• When a medication is dispensed in two different strengths or dosage forms, a separate copayment will be required for each dispensed prescription.
• Medication quantities and availability may be restricted to a lower allowed day supply when a manufacturers’ package size cannot accommodate the normal allowed pharmacy benefit day supply.
• If a medication is packaged in a day supply that is greater than a 30-day or a 90-day supply, the member’s out-of-pocket responsibility may require a copayment for each month of anticipated duration of the medication.
• If prescription mail service is included in the pharmacy benefit plan, members must use Express Scripts’ mail-order facility for 90-day coverage.
• PEHP may not cover drug quantities, dosage levels and length of therapy in excess of recommendations by the drug manufacturer, FDA, or PEHP Master Policy guidelines.

Specialty medications are high‑cost drugs that need special handling or must be filled by certain pharmacies, including PEHP’s specialty pharmacy, Accredo. PEHP may require you to use Accredo for coverage.

For traditional plans only: A pharmacy deductible is often separate from your medical deductible. You’ll pay the pharmacy deductible amount listed in your Benefits Summary when filling a prescription. Once your deductible is met, you will pay the applicable copayment or coinsurance. The cost difference between a brand‑name drug and its generic equivalent doesn’t count toward the pharmacy deductible.

For traditional plans only: The pharmacy out‑of‑pocket maximum is separate from your medical out‑of‑pocket maximum. You’ll pay the pharmacy copay listed in your Benefits Summary, and copays for preferred generics, preferred brands, and specialty medications count toward this limit. After you reach the pharmacy out‑of‑pocket maximum, those drugs are covered at 100%.

Costs that do not apply to the pharmacy out-of-pocket maximum may include non-preferred drugs, the cost difference between generic drug and brand name drugs when a substitute generic is available, and specialty medications obtained through the medical benefit.

If a brand-name drug is dispensed when a preferred generic can be substituted, you'll pay the generic co-payment plus the difference in cost between the generic and brand-name drug. If you have 100% coverage, you're still responsible for the cost difference. This may not apply to everyone; refer to your benefits summary for more information.

PLEASE NOTE:

• If you have dual coverage, you will pay the difference in cost between a generic equivalent and brand-name drug.
• If you have an HSA-qualified plan (i.e., STAR HSA Plan) and you select a brand-name medication when a generic is available, the difference in cost won't apply to your deductible and out-of-pocket maximum. If you select a brand-name medication when a generic is available, you'll still pay the cost difference even when you've met your out-of-pocket maximum. This may not apply to all groups; refer to your benefits summary for more information.
• If you have a plan with a pharmacy deductible, the cost difference between a brand-name drug and a generic equivalent doesn't apply to the deductible.

A preferred generic drug must contain the same active ingredient in the equivalent strength and dosage as the brand-name version and meet the same FDA standards. Although generic and brand-name drugs contain the same active ingredient, the inactive ingredients may differ. Inactive ingredients are used to keep a tablet from crumbling, add bulk to make it large enough to handle, and/or provide a pleasant taste or color.

Urgent and emergent prescriptions will be covered outside of the United States if the drug or class of medication is covered under the PEHP pharmacy or specialty benefit. PEHP will determine the urgent or emergent status of each claim submitted for reimbursement. Cash paid and out-of-area claims will be subject to step therapy, quantity level requirements, and preauthorization. PEHP will reimburse up to our usual and customary contract rate and benefit rules minus the required co-payment. You must provide a claim that contains the name, strength, and dosage of the medication. It's your responsibility to translate the claim into English and convert the charges to U.S. currency.