PERS ODS Advantage PPORX (PPO) pharmacy information

Formulary

The PERS ODS Advantage Comprehensive Formulary includes generic and brand-name drugs. Generic drugs are listed in lower-case italics (e.g. furosemide) and brand drugs are in capital letters (e.g. CELEBREX) by therapeutic category, followed by an alphabetic list by drug name. We have not listed all strengths for all drugs. If you do not find your drug in the formulary, it may still be a covered drug. Please call ODS Advantage pharmacy member services.

You may request a hard copy comprehensive formulary (drugs by classification and an alphabetic list) by calling ODS Advantage pharmacy member services. Please note that this list may not include all of the changes that have been made this past year or be as up to date as the version on our website.

Transition policy
New members in our plan may be taking drugs that aren't on our formulary or that are subject to certain restrictions, such as prior authorizations or quantity limits. Current members may also be affected by changes in our formulary from one year to the next.

Formulary updates

Formulary changes during the year.

Most of the changes in drug coverage happen at the beginning of each year. However, during the year, PERS ODS Advantage PPORX may make many kinds of changes to the drug list. For example we may:

• Add or remove drugs from the drug list. New drugs become available, including new generic drugs.
• Drugs get recalled and we decide not to cover it.
• We might remove a drug from the drug list because it is found to be ineffective.
• Move a drug to a higher or lower cost sharing tier.
• Add or remove a restriction on coverage for a drug.
• Replace a brand name drug with a generic drug.

In almost all cases, we must get approval from Medicare for changes we make to the drug list.

If there is a change to coverage for a drug you are taking, we will send you a notice 60 days ahead of time or give you a 60 day refill at a network pharmacy. 

• During this 60 day period you should be working with your provider to switch to the generic or to a different drug that we cover.
• Or you and your provider can ask us to make an exception and continue to cover the brand name drug for you.

Exception

An exception is a type of coverage determination that, if approved, allows you to obtain a Part D-eligible drug that is not on your plan sponsor’s formulary (a formulary exception). You may also request an exception if your plan sponsor requires you to try another drug before receiving the drug you are requesting, or the plan limits the quantity or dosage of the drug you are requesting (a formulary exception).

Coverage determination

Coverage determination is a decision from your Medicare drug plan about whether a drug prescribed for you is covered by the plan and the amount, if any; you are required to pay for the prescription. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn’t covered under your plan, that isn’t a coverage determination. You need to call or write to your plan to ask for a formal decision about the coverage if you disagree.

Pharmacy forms

• Appointment of Representative
  This form is used to name a relative, friend, advocate or anyone else as your appointed representative. This person may request a coverage determination or file a grievance or appeal on your behalf. If you want someone to act for you, then you and that person must sign the Appointment of Representative form, giving the person legal permission to act as your appointed representative.
• Coverage determination and exception request (members and providers)
  This form is used to request a coverage determination and a formulary exception request. Note: This form cannot be used to request barbiturates, benzodiazepines, fertility drugs, drugs for weight loss or weight gain, drugs for hair growth, over-the-counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations). If you are submitting a paper claim, please see the appropriate section below. You may print the pharmacy paper claim form, complete it, attach your receipt and mail it to Moda Health.
• Prescription drug redetermination request
  This form is used to request an appeal or redetermination of a denied service or coverage determination. Note: You must receive a denied coverage determination before requesting a redetermination.
• Prior authorization guidelines
  This document lists the prior authorization (PA) guidelines used to make a coverage determination for a drug noted in the comprehensive formulary with PA.

Prescription drug appeal and grievance procedure

• What to do if you have a problem or complaint - If you have a problem or complaint, please refer to your  Annual Notice of Changes — Evidence of Coverage for the PERS ODS Advantage PPORX plan, Chapter 9. This document covers how to ask for a coverage decision or make an appeal.
• How to make a complaint about quality of care, waiting times, customer service, or other concerns - If you would like more information on how to make a complaint, your Annual Notice of Changes - Evidence of Coverage for the PERS ODS Advantage PPORX plan document provides more information in Chapter 9.

If you have questions or need help with your appeal, coverage determination, exception request, redetermination or grievance, please call customer service (Contact Us). You can mail coverage determinations and exception requests to:

Moda Health Plan, Inc.
Attn: ODS Advantage Pharmacy Customer Service
P.O. Box 40327
Portland, OR 97240-0327
You may also fax to: 800-207-8235

You can mail appeals, complaints and redeterminations to:
Moda Health Plan, Inc.
Attn: ODS Advantage Appeals
P.O. Box 40384
Portland, OR 97240-0384
You may also fax to: 503-412-4003

For a report on the number of ODS Advantage PPORX grievances, appeals and exceptions, call member services.

Pharmacy network

The ODS Advantage pharmacy network contracts with more than 600 pharmacies in the state of Oregon. ODS Advantage PPORX has contracts with pharmacies that equal or exceed the CMS requirements for pharmacy access in your area. For your convenience, we contract with pharmacies throughout the U.S. and its territories.

ODS Advantage offers a wide range of choices when it comes to where and how you can order prescription drugs. The ODS Advantage pharmacy network includes retail, home infusion, long-term care and Indian health service pharmacies, and, for your convenience, a majority of national mail-order pharmacies. You can also fill up to a 90-day supply of maintenance medications at your local retail pharmacy.

The ODS Advantage Network pharmacy directory is available in a printable version for Oregon and Washington.
You must use network pharmacies to access your prescription drug benefit, except under non-routine circumstances when you cannot reasonably use network pharmacies. Quantity limitations and restrictions apply. If you use an out-of-network pharmacy, you may need to pay for your prescriptions and mail your receipt to ODS Advantage within 60 days of the fill date for processing. You will have to pay any difference between the out-of-network pharmacy's charge and the plan's allowable charge.

If you have any questions about access or mail-order services, or if you need help finding a pharmacy, please call ODS Advantage pharmacy customer service.

Out-of-network pharmacy access

Generally, we cover drugs filled at an out-of-network pharmacy only in limited, non-routine circumstances when a network pharmacy is not available. Before you fill your prescription in these situations, call customer service to see if there is a network pharmacy in your area where you can fill your prescription. If you do go to an out-of-network pharmacy for the reasons listed below, you may have to pay the full cost (rather than paying just your copayment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting your receipt. However, even after we reimburse you for our share of the cost, you may pay more for a drug purchased at an out-of-network pharmacy because the pharmacy's price is higher than what a network pharmacy would have charged. You should submit a claim to us if you fill a prescription at an out-of-network pharmacy. Any amount you pay, consistent with the circumstances listed above, will help you qualify for catastrophic coverage. To learn how to submit a paper claim, please refer to the paper claims process described next.

We will cover your prescription at an out-of-network pharmacy if at least one of the following applies:

• If you are unable to obtain a covered drug in a timely manner within our service area because there is no network pharmacy within a reasonable driving distance that provides 24-hour service.
• If you are trying to fill a prescription drug that is not regularly stocked at an accessible network retail or mail-order pharmacy (including high-cost and unique drugs).
• If you are getting a vaccine that is medically necessary but not covered by Medicare Part B.

How do I submit a paper claim?

When you go to a network pharmacy, your claim is automatically submitted to us by the pharmacy. However, if you go to an out-of-network pharmacy for one of the reasons listed above, the pharmacy may not be able to submit the claim directly to us. When that happens, you will have to pay the full cost of your prescription. Within 60 days of the fill date or when you return home (whichever is sooner), submit the receipt from the pharmacy with your name on it that lists the pharmacy, the phone number of the pharmacy, your member ID number, the prescription filled and the prescriber to the following address:

Moda Health Plan, Inc.
Attn: Pharmacy Claims
P.O. Box 40327
Portland, OR 97240-0327

You may also fax it to 1-800-207-8235

You may print the pharmacy paper claim form complete the form, attach your receipt and mail it to the above address.

If you have any questions about submitting your receipt, please call Moda Health Pharmacy Customer Service at 888-786-7509 (TTY users call 711) Seven days a week, from 7 a.m. to 8 p.m., Pacific Time.
Upon receipt, we will make an initial coverage determination on the claim. Please refer to your Annual Notice of Changes - Evidence of Coverage or call customer service (Contact Us) for more information.

ODS Advantage pharmacy quality assurance

ODS Advantage has a number of quality assurance programs to ensure you are receiving the highest quality care and service at network pharmacies and by Moda Health.

We conduct drug utilization reviews for all of our members to make sure they are receiving safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribes their medications. We conduct drug utilization reviews each time you fill a prescription and on a regular basis by reviewing our records. During these reviews, we look for medication problems such as:

• Possible medication errors
• Duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition
• Drugs that are inappropriate because of your age or gender
• Possible harmful interactions between drugs you are taking
• Drug allergies
• Drug dosage errors

If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem.

The ODS Advantage Medication Therapy Management Program (MTMP)

We offer free medication therapy management programs for members who have multiple medical conditions, who are taking many prescription drugs, and who have very high drug costs. These programs were developed by our team of pharmacists and providers. We use these programs to make sure that our members are using the drugs that work best to treat their medical conditions and help us identify possible medication errors.

If we have a program that fits your needs, we will automatically enroll you in the program and send you information.