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OEBB OPDP

Pharmacy benefits

How do I access my pharmacy benefit?

The plan's benefits will be applied at the point of service when you provide the pharmacy with your Moda Health member ID card. If you do not use your ID card or if you fill prescriptions at an out-of-network pharmacy, you can complete and submit a prescription drug claim form to request reimbursement from Moda Health. Benefits will be paid based on how the claim would have been paid if it had been submitted by an in-network pharmacy. Some out-of-network pharmacies are excluded from coverage under the plan. Contact Pharmacy Customer Service for information.

How can I find out whether a specific medication is covered under the OEBB Pharmacy benefit plan?

The plan only allows coverage for medications that are listed on the formulary. A formulary is a list of covered prescription drugs with options under the value, select generic, and preferred tiers, each corresponding to a different benefit amount as listed in the member handbook. You can find the formulary at modahealth.com/OEBB under Pharmacy Services or by logging into your Member Dashboard account.

Why are changes sometimes made to how medications are covered?

Moda Health actively manages pharmacy benefits to ensure that the plans provide quality, comprehensive coverage and remain current with industry standards and market changes.

Moda considers the following when making changes to coverage for a medication:

  • How safe is the medication?
  • How effective is the medication?
  • How cost effective is the medication?

Moda Health's clinical pharmacy team reviews the formulary and makes recommendations throughout the year. This allows Moda Health to make changes when the FDA approves new medications, when generic alternatives become available, or when changes occur for existing drugs (for example, new dosage recommendations, patient safety information, or approved uses).

Can I get a 90-day supply of medications?

You can buy up to a 90-day supply of non-specialty medications at either PPS or Costco mail-order pharmacies and at almost all retail pharmacies if your doctor's prescription allows you to receive a 90-day supply.

How do I use a mail-order pharmacy?

If you are filling a new prescription, ask your doctor to send the prescription to the mail order pharmacy. If you are transferring a prescription, contact the pharmacy and they will work with your prior pharmacy to transfer the prescription. In some cases, you may need a new or updated prescription from your doctor to allow the 90-day supply. The pharmacy will also reach out to the doctor's office to initiate this and will let you know if you need to contact the doctor yourself.

The mail-order pharmacies available to OEBB members are:

Make sure to use the member ID number found on your ID card to set up an account with the mail-order pharmacy.

Once my mail-order pharmacy account and prescription(s) are established, how do I place orders for refills?

You can place orders for refills and check the status of your prescriptions by visiting the pharmacy's website and logging in to your account. In most cases you will need to manually request refills, but pharmacies may offer an auto-refill option or send you reminders when it is time to refill.

If a prescription costs less than the copayment, do I pay the total cost of the prescription or the copayment?

You pay the total cost of the prescription or the copayment, whichever is less. You will never pay more than the total cost of the prescription.

If a I am traveling out of state, how does prescription drug coverage work?

You have access to in-network pharmacy benefits nationwide, as long you fill prescriptions with an in-network pharmacy. A list of in-network pharmacies is available on the Member Dashboard or on the Moda Health website under Find Care by selecting the NW Prescription Drug Consortium Core pharmacy network in the drop-down list within the search tool.

If you use an out-of-network pharmacy, you must submit your claims and receipts for reimbursement. You can obtain prescription drug claim forms online through your Member Dashboard or at https://modahealth.com/members/forms.shtml. The plan will pay based on how the claim would have been paid if it had happened at an in-network pharmacy.

If I forgot to give the pharmacy my ID card or went to an out-of-network pharmacy, how do I submit a request for reimbursement?

You will need to complete the Prescription Drug Claim form (also available on your Member Dashboard) and mail or fax it to:

Pharmacy Manual Claims
P.O. Box 999
Appleton, WI 54912-0999
Fax: 855-668-8550

If a I have multiple pharmacy plans and Moda Health is the secondary plan, how will the secondary claim be paid?

When the primary plan has approved and paid a pharmacy claim, the plan will pay up to what would have been covered if the Moda plan was primary, but not more than the out-of-pocket expense from the primary claim.

If the primary plan denies the claim or paid nothing toward the claim (for example, when the cost of the medication is less than the copay), then the secondary plan will process the claim as if it is the primary plan.

Plans 1-5 pharmacy coordination of benefit examples:

  • Generic medication, 31-day supply dispensed, primary plan is with a different carrier, secondary plan is an OEBB Moda Health Plan ($12 copay)
    • The member's primary insurer allows $150, pays $100, and the copay/coinsurance is $50.
    • If the Moda Health plan had been primary, it would have used a $60 allowed amount, applied a $12 copay and paid $48 toward the claim.
    • Because the Moda Health plan would have paid $48 as primary, it will pay up to $48 as secondary. This means that the plan pays $48, and the member must pay the remaining $2.
  • Preferred brand medication, 31-day supply dispensed, member is covered under two OEBB Moda Health plans (25% up to a $75 max)
    • The Moda Health contracted rate on the medication is $150.
    • The primary plan pays $112.50, and the member's copay is $37.50.
    • The secondary plan also would have paid $112.50 if it were primary, and the member would have had a $37.50 copay.
    • Because the secondary plan would have paid $112.50 as primary, it will pay up to $112.50 as secondary, but not more than the patient responsibility left after the primary plan pays. This means that the secondary plan pays the full $37.50 primary plan copay and the member has a balance of $0 to pay after both plans' payments.

Plans 6 and 7 pharmacy coordination of benefit examples:

  • Brand medication, 31-day supply dispensed, primary plan is with a different carrier, secondary plan is Moda Health Plan 6 (20% copay)
    • The member's primary plan pays, and the member's remaining out-of-pocket expense is $200.
    • If the claim had been processed through the Moda Health plan as primary, the contracted rate would have been $300. Assuming the deductible has been met, the plan would have paid $240, and the member would have had a $60 copay.
    • Because Moda Health would have paid $240 as primary, we will pay up to $240 as secondary, but not more than the $200 patient responsibility applied on the primary plan. This means that the Moda plan pays the full $200 primary patient responsibility, and the member has a balance of $0 to pay after both plans' payments.
If I request a name-brand medication that has a generic alternative, how much will I need to pay?

If you request a brand-name drug or your provider prescribes a brand-name drug when an equivalent generic is available, you will be required to pay the brand copayment or coinsurance, plus the difference in cost between the generic and brand-name medication.

How will I know if my medications require prior authorization or have limitations?

Review the prescription drug formulary at www.modahealth.com/oebb under Pharmacy Services or by logging in to your Member Dashboard and using the prescription price check tool. Please note that this list may change periodically. You can also call the Moda 360 Health Navigator team at 866-923-0411.

What should I do if my medication requires authorization?

If a medication is listed on the formulary as requiring authorization or if you are taking a specialty medication, ask your provider to submit the prior authorization request. You can also contact the Moda 360 Health Navigator team at 866-923-0411 to find out if your medication needs authorization, and a Health Navigator can contact your provider's office to help them start the authorization process.

How does the pharmacy benefit for medical Plans 6 or 7 (the HSA-compliant plans) work?

For most covered medications, you will pay the full allowed amount for medications until your deductible has been met, at which point you will pay a percentage. For value tier medications, you pay a fixed copayment or the cost of the medication (whichever is less). These costs count toward your out-of-pocket maximum.

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