How can I submit for reimbursement for my pharmacy co-payment if I am covered by two PEHP plans (dual coverage)?

Dual coverage is defined as enrollment in two PEHP medical or pharmacy plans. To coordinate your pharmacy deductible, co-payment, or co-insurance with your secondary PEHP plan, you have to submit your pharmacy receipts and an Express Scripts Direct Claim Form to Express Scripts.

How do I submit pharmacy claims if I have coverage with another plan or have paid cash for my prescription?

Coordination of benefits (COB) claims are claims your primary insurance has already paid and PEHP becomes your secondary insurance. Cash-paid (direct) claims are those you paid the cash price for your medicine without using your pharmacy card. 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 can obtain a Express Scripts Direct Claim Form at Direct Claim Form.

How can I appeal a decision?

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 Policy Management Department
PO Box 3836
Salt Lake City, Utah 84110-3836

What can cause my mail service prescription to be delayed?

Express Scripts has a good track record for quickly filling prescriptions, but certain things could delay shipment:

• Missing information.
• Prescription not written for a 90-day supply.
• Drug interactions.
• Uncommon dosages.
• Lack of preauthorization 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.

What does "maintenance medication" mean?

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

Non-maintenance medications are not available through mail-order. Some examples are: pain management medications, muscle relaxants, cough and cold medications, anti-migraine, antibiotics, sleeping and anti-anxiety pills.

What is the advantage of mail-order?

The main advantage is maintenance drugs are available via mail-order in 90-day quantities and at less expense than at a retail pharmacy. Examples of maintenance medications include those for: diabetes, depression, asthma, blood pressure, birth control, as well as anticonvulsants. Examples of medications not available through mail-order are: pain therapies, muscle relaxants, antibiotics, anti-anxiety drugs, anti-migraine drugs, and injectables.

To receive your 90-day supply through mail-order:

• Obtain a prescription for a 90-day supply from your doctor
• Complete the Express Scripts by Mail Order Form
• Be sure you have obtained preauthorization if required
• Enclose your required co-payment and mail to:
  

  EXPRESS SCRIPTS

  PO BOX 66564

  ST. LOUIS, MO 63166-6564

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

Does the preferred drug list change?

It changes twice a year based on FDA reviews of new medications and generic equivalents. Exceptions are based on FDA or PEHP Pharmacy and Therapeutics Committee recommendations.

Will PEHP pay for a medication not listed on the preferred drug list?

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.

When may I refill my prescription?

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

Can I continue to receive my specialty medication through my medical provider?

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. In these cases, PEHP will offer your specialty medication for a lower co-payment through our specialty pharmacy and that will save you money. If you still chose 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, for medications you receive through a provider's facility. Co-payments through Accredo don't apply to the specialty out-of-pocket maximum. Check your Benefits Summary for your maximum cost. Call PEHP at 801-366-7555 or 800-765-7347 for information or help making the transition to Accredo.

Do specialty medications require preauthorization?

Most do. Go to www.pehp.org/members/prescription-drug-benefit/preauthorization to learn whether your drug requires preauthorization, or call PEHP at 801-366-7555 or 800-765-7347. Your physician can obtain a preauthorization form from the provider section of www.pehp.org or by calling the number above.

What are some limitations to my pharmacy benefits?

• Drug quantities, dosage levels, and length of therapy may be limited to the recommendations of the drug manufacturer, FDA, clinical guidelines, or PEHP's Pharmacy and Therapeutics Committee.
• PEHP may classify an FDA approved generic medication as non-preferred, or not covered, when directed by the Pharmacy and Therapeutics Committee.
• When a medication is dispensed in two different strengths or dosage forms, a separate co-payment will be required for each dispensed prescription.
• Medication quantities and availability may be restricted to a lower allowed daily supply when a manufacturers' package size cannot accommodate the normal allowed pharmacy benefit daily supply.
• If a medication is packaged in a supply greater than 30-days, the member's out-of-pocket responsibility may require a co-payment for each month of anticipated duration of the medication.
• If prescription mail service is included in the pharmacy benefit plan, members must use ExpressScripts 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.

What are specialty medications?

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 buy your speciality medications through Accredo for coverage. You can find out where to buy your specialty medication, to make sure you have coverage, at www.pehp.org/members/prescription-drug-benefit/specialty-medications

What is preauthorization?

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

What is a generic substitution 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 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., The STAR 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 continue to 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.

What is the difference between a generic and a brand-name medication?

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.

How can I lower my copayment?

Ask your doctor if your prescription is available in an equivalent generic, many are, and preferred generics have the lowest copayment. If you can't get an effective generic equivalent, ask your doctor and/or pharmacist if a preferred brand-name drug will work. (See the PEHP Preferred Drug List for further suggestions.)

Can I be reimbursed for urgent or emergent medications I have purchased outside of the United States?

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 covert the charges to U.S. currency.

How does my plan work if I have a pharmacy out-of-pocket maximum?

A pharmacy out-of-pocket maximum is separate from your regular medical out-of-pocket maximum. When filling your prescription, you'll pay the pharmacy co-payment listed in your Benefits Summary. Preferred generics, pharmacy specialty medications, and preferred brand co-payments will apply to your pharmacy out-of-pocket maximum listed in your Benefits 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 include non-preferred drugs, the cost difference between generic and brand-name drugs when a substitute generic is available, and specialty medications obtained through the medical benefit.

How does my plan work if I have a pharmacy deductible?

A pharmacy deductible is often separate from your regular medical deductible. When filling your prescription, you'll pay the pharmacy deductible listed in your Benefits Summary. Once your deductible is met, you'll pay the applicable co-payment or co-insurance.

What is my co-payment or co-insurance responsibility?

Members are responsible for the co-payment or co-insurance of the medication at the time of purchase. The co-payment and/or co-insurance is based on your employer group's pharmacy plan selection. If the cost of the medication is less than the specific co-payment and/or co-insurance listed for that medication, you are responsible for the lesser amount.

Where can I access the Preferred Drug List?

Find the Preferred Drug List at Preferred Drug List

How does my pharmacy/medical identification card work?

Your prescription card serves as both your pharmacy and medical ID card. Present your card at your pharmacy or provider’s office at the time of service. Your card will come directly from Express Scripts, PEHP’s pharmacy benefit manager. New PEHP members will receive a PEHP card shortly after enrollment. A new card will not be reissued at each new enrollment unless your benefit coverage changes. If you lose your card or need additional copies for dependents, you may log into www.express-scripts.com, register to use their site, select Forms and Cards, and request a replacement card. You may also print a temporary card. Members may also call PEHP at 801-366-7555 or 800-7657347 to order a new ID card.