Prescription Drug Services

Transcription

1 Prescription Drug Services Table of Contents Prescription Drug Services... 1 Formulary... 1 Copayments for Drugs... 2 Retail Pharmacy Benefit... 2 Mail Order Pharmacy Benefit... 3 Nonformulary and Prior Authorization Requests... 3 Health Coverage When You Travel... 3 Using an Out-of-Network Pharmacy in an Emergency... 3 Your Right to Safe and Effective Pharmacy Services... 4 Frequently Asked Questions About Pharmacy... 4 Prescription Drug Services Community Health Plan s pharmacy network includes pharmacy chains and neighborhood drug stores. You must get your prescription filled at a pharmacy in the Community Health Plan network. To get a list of pharmacies in the Community Health Plan network: See the 2010 Community Health Plan Provider and Pharmacy Directory. Visit the Provider Directory Search online, which is updated as provider and pharmacy lists change. Call the Community Health Plan customer service team at toll free. If you are hearing or speech impaired, please call TTY toll free or local Formulary Community Health Plan uses a formulary system, which means we only pay for approved drugs. A group of providers and pharmacists develops this list of approved drugs based on safety, effectiveness, and cost. If you have any questions about our formulary or why we limit or will not pay for drugs that are not on the approved list (the formulary), please call the Community Health Plan customer service team at toll free. If you are hearing or speech impaired, please call TTY toll free or local Community Health Plan. Information in this document is accurate at the date of its creation. Check for updates at or by calling our customer service team,

2 Community Health Plan cares about your safety. That is why we do not cover certain types of medications, such as experimental drugs and drugs that have not been approved by the government. We also have limits, such as quantity limits, to help you use your medicine safely. To find out which drugs are covered on the Community Health Plan formulary: You can search for the formulary status of a drug online. You can call the Community Health Plan customer service team at toll free. If you are hearing or speech impaired, please call TTY toll free or local You can get a copy of the formulary by calling the Community Health Plan customer service team. (See contact information directly above.) Copayments for Drugs If the cost of the drug is less than the $10 copay, the member is responsible for only the cost of the drug. Tier 1: $10 Copay Generic drugs contained in the Community Health Plan drug formulary All oral contraceptives in the Community Health Plan drug formulary Diabetic supplies, including syringes and needles, diabetic test strips, lancets and insulin Inhaled short-acting beta-agonists Inhaled steroids Inhaled anti-cholinergic bronchodilators Beta-blockers for severe heart failure Anti-platelet clotting inhibitors for patients after intra-arterial stent placement. Tier 2: 50% Copay Brand-name drugs in the Community Health Plan drug formulary Retail Pharmacy Benefit You can get up to a 30-day supply of prescribed drugs at a participating retail pharmacy. Page 2

3 Mail Order Pharmacy Benefit Community Health Plan does not have a mail order pharmacy benefit. Nonformulary and Prior Authorization Requests If you need a drug that is not covered or requires prior authorization, your provider may ask us to pay for it. Your provider request does not guarantee that we will pay for the drug your provider asks us to pay for. Your provider must call or send nonformulary requests to: PA Dept-CHW Express Scripts, Inc W. 78th St. Mail Route BL0345 Bloomington, MN Phone: Health Coverage When You Travel While you are traveling or are out of our service area, Community Health Plan or a State program pays for medically necessary emergency care, urgent care, and follow-up care that cannot wait until you get home. (For more information about emergency treatment, see "Using an Out-of-Network Pharmacy in an Emergency.") You may fill your prescription at any of our nationwide pharmacies. If you need a 30-day supply of a prescription before you go on vacation, please ask your PCP before you leave. If you need more than a 30-day supply, please call the Community Health Plan customer service team at the number below. For more information, please call the Community Health Plan customer service team at toll free. If you are hearing or speech impaired, please call TTY toll free or local Using an Out-of-Network Pharmacy in an Emergency If you have an emergency while traveling and out of our service area, call 911 or go to the nearest emergency room. You must tell your PCP within 24 hours after your emergency room or urgent care center visit or as soon as your health allows. We will pay for a limited supply of drugs from a pharmacy outside of our network when you get it for emergency treatment and you cannot find an in-network pharmacy. If you have to pay for the drug, Community Health Plan will pay you back. You will still need to pay your copay. Page 3

4 If you had to pay for your prescriptions in an emergency, ask for a reimbursement form by calling the Community Health Plan customer service team at toll free. If you are hearing or speech impaired, please call TTY toll free or local You can also get the form on this web site. Fill out the form and send it with your receipt for the prescription to: Express Scripts, Inc. Attn: Claims Dept. P.O. Box Bloomington, MN Your Right to Safe and Effective Pharmacy Services State and federal laws set rules for safe and effective pharmacy services. These laws give you the right to know what pharmacy services are paid for by your plan. If you would like more information about what pharmacy services are paid for by Community Health Plan, please call the Community Health Plan customer service team at toll free. If you are hearing or speech impaired, please call TTY toll free or local Frequently Asked Questions About Pharmacy 1. Does this plan limit or exclude certain drugs my health care provider might prescribe? The Community Health Plan drug formulary is formed by an independent Pharmacy and Therapeutics (P&T) Committee. This P&T Committee is made up of Washington State providers and pharmacists from various medical specialties. The P&T Committee members review medications based on safety, effectiveness, and cost, selecting the products that show the most value in each class. Community Health Plan's formulary is a mandatory generic formulary. This means that the brand-name product will not be paid for without first trying the formulary generic product. 2. When can my plan change its drug formulary list? If a change occurs, will I have to pay more to use a drug I had been using? The Community Health Plan P&T Committee reviews the formulary several times each year to make sure Community Health Plan covers needed drugs. When the formulary is updated, changes are posted online. In most cases, you will be given 60 days written notice if Community Health Plan removes your drug from the formulary. In some cases when a drug is removed from the formulary you will need to pay more for the drug. Page 4

5 3. What should I do if I want a change from limitations or exclusions for drugs specified in this plan? Your PCP should call Community Health Plan's pharmacy benefit manager, Express Script, Inc. (ESI), at , 24 hours a day, seven days a week, to ask for formulary exceptions such as quantity limit changes and nonformulary drugs. A decision might be made during the call for both normal circumstances and emergency medical conditions. The decision may take up to 3 business days. 4. What should I do to ask for a drug excluded by my medical plan? If your drug won't be paid for when you try to fill the prescription at the pharmacy, you have the right to appeal. If you want to appeal, please call the Community Health Plan customer service team at toll free. If you are hearing or speech impaired, please call TTY toll free or local How much do I have to pay to get a prescription filled for a formulary drug at a network pharmacy? In general, you pay a $10 copay per prescription for Tier 1 formulary generic drugs. If the prescription costs less than $10, you pay only the cost of the drug. You pay 50% of the prescription cost for Tier 2 formulary brand-name drugs and exception-approved nonformulary brand-name and generic drugs. For more detailed information about prescription costs, see the table in Copayments for Drugs. 6. Do I have to use certain pharmacies? Yes. Community Health Plan works with more than 1,000 participating pharmacies in Washington State. To learn which pharmacies work with Community Health Plan: See the 2010 Community Health Plan Provider and Pharmacy Directory. Visit the Provider Directory Search online, which is updated as provider and pharmacy lists change. Call the Community Health Plan customer service team at toll free. If you are hearing or speech impaired, please call TTY toll free or local Page 5

6 7. How many days supply of most medications can I get? You can get up to a 30-day supply of prescribed drugs. 8. What other pharmacy services does my health plan pay for? The pharmacy services only pay for formulary medications. To find out more about your rights under the law, call the Washington State Office of the Insurance Commissioner at If you have a problem or concern about the pharmacist or pharmacy serving you, please call the Washington State Department of Health at Page 6