Forms & FAQs

For most Members, your prescription card will serve as your medical, pharmacy, dental, and out-of-state network ID card. Present it at your pharmacy, doctor or dentist’s office at the time of service. Your card will come directly from Express Scripts, PEHP’s pharmacy benefit manager.

When PEHP is your secondary carrier, you must buy your prescriptions through your primary carrier. PEHP will coordinate coverage of eligible co-payments and unpaid pharmacy claims if they meet PEHP's benefit, coverage, preauthorization, and quantity requirements.

You must submit an original itemized receipt (a pharmacy printout is not a valid receipt) and a claim form to Express Scripts. PEHP will reimburse you up to our usual and customary contract rate and benefit rules minus the required co-payment.

When PEHP is your secondary carrier, you must buy your prescriptions through your primary carrier. PEHP will coordinate coverage of eligible co-payments and unpaid pharmacy claims if they meet PEHP’s benefit, coverage, preauthorization, and quantity requirements.

You must submit an original itemized receipt (a pharmacy printout is not a valid receipt) and a claim form to Express Scripts. PEHP will reimburse you up to our usual and customary contract rate and benefit rules minus the required co-payment.

You or your prescribing physician can initiate an appeal to any coverage decision made by the PEHP Pharmacy Department. A request for a full and fair review must be made 180 days after receiving notice of denial. Mail requests to: PEHP Appeals and Management Department, P.O. Box 3836, Salt Lake City, UT 84110-3836

Ask your doctor if your prescription is available in a generic. Many are, and preferred generics have the lowest copayment. If you can’t get a generic, ask your doctor and/or pharmacist if a preferred brand-name drug will work. (See the PEHP Covered Drug List for further suggestions.) Visit www.express-scripts.com and use the myRX Choices tool to price medication.

• 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.

Some drugs require preauthorization due to their potential for misuse, adverse reactions and safety concerns.

At www.pehp.org you will see which drugs require preauthorization. Your doctor can obtain a preauthorization form from the provider section of www.pehp.org or may call PEHP at 801-366-7555 or 800-765-7347.

These costly drugs require special handling and shipping or are required by the manufacturer to be dispensed by a specific pharmacy, such as PEHP’s specialty pharmacy, Accredo. PEHP may require you to obtain your specialty medications through Accredo for coverage. Find out where to obtain your specialty medication at www.pehp.org/Prescription Drug Benefit/Specialty Medications.

For traditional plans only: A pharmacy deductible is often separate from your regular medical deductible. When filling your prescription, you will pay the pharmacy deductible listed in your Benefits Summary. Once your deductible is met, you will pay the applicable copayment or coinsurance. 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.

For traditional plans only: A pharmacy out-of-pocket maximum is separate from your regular medical out-of-pocket maximum. When filling your prescription, you will pay the pharmacy copayment listed in your Benefits Summary. Preferred generics, pharmacy specialty medications and preferred brand copayments will apply to your pharmacy out-of-pocket maximum that is listed in your Benefit Summary. Once your pharmacy out-of-pocket maximum is met, preferred generics, pharmacy specialty medications, and preferred brand name drugs will be covered at 100%.

Out-of-pocket 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.

A maintenance medication is any prescription taken daily. Some examples are: antidepressants, asthma medications, birth control pills, cholesterol medications, blood pressure medications, and anticonvulsants. Maintenance medications are available through home delivery.

The medications have been chosen by PEHP's Pharmacy and Therapeutics Committee (a team of physicians, nurses, and pharmacists from the Intermountain area). They choose medications that provide the best overall value based on quality, safety, effectiveness, and cost. The Covered Drug List may be modified periodically with changes based on the Pharmacy and Therapeutics Committee's recommendations.

Probably, but it will have the highest co-payment. Coverage depends on your plan benefits. For information call PEHP at 801-366-7555 or 800-765-7347.

Retail and home delivery prescriptions may be refilled once you've consumed 75% of your supply. Retail orders require 23 days between refills and 68 days for home delivery. Maintenance drugs carry a 75% refill allowance when used within the last 180 days.

For most specialty drugs, PEHP requires you to use our specialty drug vendor (Accredo) for coverage. Sometimes specialty drugs may be available through both our specialty drug vendor and through your doctor's office, but you will have a lower co-payment through our specialty drug vendor. If you choose to receive your specialty medications from your doctor's office, preauthorization may be required, and you may also have a separate out-of-pocket maximum of $3,600 per member, per year.

Most do. To learn more, visit www.pehp.org/pharmacy or call PEHP at 801-366-7555 or 800-765-7347.

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 all groups; 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.

This is possible if your doctor has not indicated that a brand-name is necessary. If your medication has no generic, but generics are available for your medication class, see if your doctor will switch it to give you a lower copayment.

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.

The main advantage is that maintenance drugs are available via home delivery in 90-day quantities.

To receive your 90-day supply through home delivery.

• Obtain your doctor’s prescription for a 90-day supply.
• Complete the “Express Scripts Home Delivery Order Form” at /pharmacy/forms.
• Ensure you have obtained a pre-authorization if required.
• Enclose your required copayment and mail to the address on the form.

Your order will arrive in about 14 days. Be sure to have at least a two-week supply on hand so you don’t run out while waiting.

Express Scripts is committed to quickly filling prescriptions, but certain things could delay shipment:

• Missing information.
• Prescription not written for a 90-day supply.
• No refills.
• Drug interactions.
• Uncommon dosages.
• Lack of pre-authorization when required.
• A duplicate prescription filled too soon at a local pharmacy.

Be sure to have at least a two-week supply on hand in case you have to wait.