Pharmacy Information for Providers
We look at our members holistically; offering coordinated medical and pharmacy benefits to help close gaps in care and improve members’ overall heath. Our goal is to help improve your patients’ health outcomes by combining medical, pharmacy and lab data ensuring coordination of our people, programs and knowledge.
Prescription Drug Plan
We use drug lists, along with gaps-in-care messaging, to support overall member health. We look at how drugs work in the real lives of our members, then use our medical and pharmacy data and analyze claims analysis to make sure the medications really work.
But that’s just the beginning.
Improving the Health of Our Members
We encourage medications that improve patient health. We see how drugs work in our members’ real lives and help them make good health care choices.
Reducing Total Health Care Costs
Cost-of-care and clinical programs focus on total costs, and we encourage medications that help to reduce those total costs. Both medical and pharmacy costs are our responsibility.
Ensuring Coordination of Care
Medical and pharmacy strategies complement each other; they’re based on the same goals. Policies are aligned. We engage members and you, their doctors.
Simplifying the Member Experience
Our medical and pharmacy experts work collaboratively. Members have one vendor, one contact, and one ID card. Clients have one vendor, one contact, one contract, one eligibility feed, and one invoice.
Some drugs, and certain quantities of some drugs, require an approval before they are eligible for coverage. The Prior Authorization process allows for the request and approval of these medications.
Online Prior Authorization Requests
Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of the these ePA sites:
Prior Authorization Requests by Phone or Fax
We encourage providers to use the online process through CoverMyMeds or Surescripts for submitting Prior Authorization requests. If you’d like to submit a request using the traditional phone or fax method, please use the following contact numbers. For pharmacy benefit questions, members should call the Member Service number on their ID card.
Commercial (Off Exchange): 833-293-0659
On Exchange: 833-293-0660
Commercial (Off Exchange): 844-521-6939
On Exchange: 844-534-9057
Member and Physician Engagement
We drive compliance to improve health and reduce costs. By using targeted, concise communication, we help members make good health care choices and improve health outcomes. Members don’t receive multiple letters focused on individual clinical and cost-of-care programs. Gaps-in-care messaging for our clinical and cost-of-care programs is included in one communication. And to help ensure coordination of care and compliance, physicians also receive a consolidated communication with similar messages.
Once we identify a gap in care, the member receives a personalized Medication Review, which contains pharmacy messaging for our clinical and cost-of-care programs in one consolidated, health plan-branded, monthly member communication.
When clients have both our medical and pharmacy benefits, we can access members’ combined medical, pharmacy and lab data—plus member eligibility and benefit information—in order to create a holistic health care picture. This allows us to send generic and therapeutic equivalent messages with member-specific cost savings.
Controlled Substance Utilization Review
Our Patient Highlights communication is focused on controlled substance care opportunities, including the identification of members receiving multiple controlled substance medications, high-dose opioids or opioids from multiple providers and filled at multiple pharmacies, or combinations of controlled substances that may indicate risk.
Drug List Management
We are leading the health care industry in the way we choose covered drugs, analyzing the strongest clinical drug studies and member data to see how drugs are really working for patients. We believe the right drugs to cover are the ones that do the best job for our members and reduce the total cost of care.
Pharmacy & Therapeutics (P & T) Committee
A group of doctors and pharmacists from outside our organization lead the selection of drugs included in our drug lists. This group performs regular clinical reviews, rates drugs based on how they work in real life, evaluates drug costs to make sure they are affordable, and chooses drugs that are safe, work well and offer the best value.
We look at claims data to find opportunities for our members to save money by switching them to lower-cost, therapeutically equivalent drugs. We send members personalized messages about medications that may reduce their costs and include specific cost savings.
Generic Drug Strategy
We take a comprehensive approach to encourage generic drugs and help keep our members healthy and reduce costs.
90-Day Medication Prescriptions
We offer home delivery, as well as Retail 90 and Smart 90 pharmacy networks as options for members to fill up to a 90-day supply of their medications. When you write the new prescription, you can fax or efax the form and prescription to the phone number on the form. We’ll take it from there.
Pharmacy Home Program
The Pharmacy Home Program identifies members who may be over-utilizing providers, medications and pharmacies to obtain controlled substances. After a warning period to correct behavior, members become restricted to one pharmacy, designated as the “home pharmacy.” A partnership with our providers will enhance this program’s ability to reduce the risk of opioid misuse and enable earlier identification of members facing substance use-related conditions.