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Prescription Drug Coverage Frequently Asked Questions for PPO $900 Deductible and PPO-Plus Participants
Effective January 1, 2005
Question: What can I do to make sure I have the prescription medicines I need on January 1?
For maintenance drugs (drugs you take on an ongoing basis), plan ahead. Be sure to obtain a refill through ScripPharmacy or your retail pharmacy before the end of the year. The university has worked with ScripSolutions to make refills available after only half of your most recent prescription has been used. In addition, you may check with your pharmacist to see if an early refill option is available to you. These are sometimes called "vacation overrides" or "early refills."
Plan participants may also need medicines to treat unexpected acute conditions (e.g., antibiotics) right away. Keep in mind that you do not need a prescription identification card to obtain your benefits at a retail store on January 1 or after. If you have your new medical identification card, present it to the pharmacist. If not, give the retail pharmacist your name, date of birth, indicate that your benefits are administered by Anthem Prescription effective January 1 and that your Benefit Identification Number (BIN) is 610575 . (A temporary prescription benefit card with the BIN number will be available on the University Human Resource Services Web page www.indiana.edu/~uhrs for those who wish to print it.)
Question: If I currently have refills left on a mail order prescription with ScripSolutions, how do I get my prescription through the new Anthem Rx Direct mail service?
If you currently use mail service through ScripPharmacy and have refills left on your prescriptions, it is anticipated that your prescription information will automatically transfer to Anthem Prescription after January 1, 2005. This will mean that in most cases, Anthem Rx Direct will be able to handle your refill prescriptions without any interruption to you. Follow these steps:
- Call Anthem Rx Direct at 800-962-8192. For speech and hearing impaired assistance, call TTY (800) 221-6915 .
- Provide your prescription information and designate your payment preferences; if you wish to pay by check rather than credit card you will be given directions on how to submit payment
- Allow at least 15 business days for processing and delivery.
Remember, even if you have refills remaining, controlled substance products and specially mixed medications like compounds cannot be transferred automatically. In these situations, you will need to obtain a new prescription from your physician. Also note that internet refills cannot be accepted for first time refills on transferred prescriptions.
While we are optimistic about receiving the electronic files needed to automatically transfer prescription information from ScripSolutions to Anthem, it is possible that the data transfers could be delayed or unsuccessful. In this event, you will need to obtain new prescriptions and submit them as a new order.
Question: How do I initiate a new prescription order with Anthem mail order?
For new mail pharmacy orders, customers must have a new prescription, written for a 90-day supply. They then complete an order form and send it to Anthem Rx Direct with the original prescription and appropriate copayment. The order form is available to download at www.anthemprescription.com. A form is also enclosed in this mailing.
Question: How do I move my prescription from one retail pharmacy to another retail pharmacy?
If refills remain on your current prescription, take your prescription bottle to the new pharmacy or call the new pharmacy with the information from your prescription bottle. The new pharmacist will make the necessary calls to transfer your prescription. Take your new Anthem ID card with you to pick up your first prescription at a participating pharmacy. If you do not have your new ID card, give the pharmacist your name, date of birth, and the Anthem Benefit Identification Number, 610575.
Question: If I am not changing to a new retail pharmacy and I still have refills on my current prescription, do I need to present my new pharmacy ID card?
Yes, if you have your new medical identification card, present it to the pharmacist. However, an identification card is not needed to obtain benefits - give the retail pharmacist your name, date of birth, indicate that you have Anthem Prescription benefits effective Janaury 1 and that your Benefit Identification Number (BIN) is 610575. (A temporary prescription benefit card with the BIN number will be available on the University Human Resource Services Web page www.indiana.edu/~uhrs for those who wish to print it.)
Question: I currently have refills left on a prescription at a retail store, how do I move my prescription from retail to mail:
Anthem Prescription offers a help desk (888-613-6091, Monday through Friday, 8 a.m. to 6p.m. Eastern Time) for first-time users to ease the transition from retail to mail. This help desk assists customers in converting their maintenance medication prescriptions from a retail pharmacy to the Anthem Rx Direct mail service pharmacy. Customers can call the help desk, provide key personal and medical provider information, as well as details about the prescription(s). The Anthem Rx Direct Customer Service representative then contacts the customer's physician(s) to secure prescriptions written for the maximum days supply allowed by the customer's pharmacy benefits. After receiving the new prescriptions, Anthem Rx Direct dispenses the customer's medications and ships them to the address provided during the initial telephone call.
Please allow time for processing and delivery of your prescription. The time required will depend on how quickly your physician's office responds to Anthem's request for information.
Question: I currently purchase my diabetic supplies through ScripSolutions mail order or a retail pharmacy. Can I continue to do that?
PPO plan participants will continue to receive prescription drug coverage, including covered diabetic supplies, through the Anthem Prescription retail pharmacy network or mail order pharmacy.
Pharmacy benefit coverage will apply to test strips, urine test strips, insulin syringes, and lancets. Coverage for glucometers will occur under your medical benefit for durable medical equipment.
Question: If I purchase and pay for a prescription at an out-of-network pharmacy, how do I get reimbursed?
If the date of purchase is on or after January 1, 2005, reimbursement will be coordinated through Anthem Prescription. Prescriptions received from participating retail pharmacy providers are submitted by the pharmacy through an online claims processing system and do not normally require any paperwork. Some non-network or out-of-area pharmacies can handle claims electronically without paperwork for you. Your benefit for out of network pharmacy purchases is 50% of the prescription cost.
In instances where the provider is unable to submit claims electronically, the customer is required to complete a Direct Member Reimbursement (DMR) claim form and provide a copy of the receipt from their prescription purchase. The DMR claim form and receipts for medications must be submitted directly to Anthem Prescription at the address on the form within 60 days after the date of service and are subject to drug utilization review. Direct Member Reimbursement claims are processed manually. Reimbursement checks and explanations of payment are then mailed to the customer within approximately 15 to 30 days. A DMR claim form may be downloaded from the Anthem web site at www.anthemprescription.com, or may be requested by contacting Anthem's Customer Service.
If the date of purchase is prior to January 1, 2005 , complete a ScripSolutions direct member reimbursement claim form, which is available on the University Human Resource Services website, campus Human Resources Offices, or by contacting Scrip Pharmacy Solutions Customer Service at 800-213-5640. Attach all necessary receipts and mail to ScripSolutions at the address on the form. Allow 6-8 weeks for your check. You will be reimbursed 50% of the prescription cost.
Question: I currently have a letter from my physician to authorize coverage of a certain drug. Do I need to obtain another authorization with Anthem?
Prior Authorization is the process of obtaining approval before benefits for certain prescriptions may be approved. The Prior Authorization process is normally used to monitor the prescribing of certain drugs in order to promote access to safe and cost-effective prescription benefits.
As new customers to Anthem Prescription Management, it is anticipated that all current authorizations for drugs that require Prior Authorization will be transferred to Anthem Prescription's database. This transfer of data will allow for the continued receipt of your medication as outlined in the authorization. Although we are optimistic that this data transfer will take place, it is possible that it will not be successful. In this event, you would need to obtain a new authorization as described in the next question.
Question: What if I have a new prescription for a drug that requires prior authorization?
Prior Authorization is the process of obtaining approval before benefits for certain prescriptions may be approved. The Prior Authorization process is normally used to monitor the prescribing of certain drugs in order to promote access to safe and cost-effective prescription benefits.
When your physician has prescribed a medication that requires a Prior Authorization, your pharmacist will receive an electronic message sent to their computer at the point of sale.
Your pharmacist has the ability to call Anthem Prescription directly for benefit approvals on some medications that require Prior Authorization. This process may save you and your pharmacist valuable time. If the pharmacist and Anthem Prescription are not able to get enough information to process the Prior Authorization for your medication, your physician will need to call 800-338-6180 or fax 800-601-4829 with the needed information.
Question: What if I don't have my ID card on January 1, 2005, and I need a prescription filled?
You do not need a prescription identification card to obtain your benefits at a retail store on January 1 or after. Give the retail pharmacist your name, date of birth, indicate that you have Anthem Prescription benefits effective Janaury 1 and that your Benefit Identification Number (BIN) is 610575 . (A temporary prescription benefit card with the BIN number will be available on the University Human Resource Services Web page www.indiana.edu/~uhrs for those who wish to print it.)
Question: What if I go to a retail pharmacy after January 1 and they tell me I don't have prescription coverage?
If the pharmacy system doesn't have record of your coverage please contact Anthem so that they can verify eligibility with your health plan and adjust the system so that you will only be charged your copayment.
If for any reason you have to pay the entire cost of a prescription, you may obtain reimbursement by submitting a Direct Member Reimbursement claim form and the receipt(s) for your prescription to the address on the claim form.
You can obtain a claim form by downloading it from www.Anthem.com or by contacting Anthem Customer Service.
Question: My physician says that I must use a brand name prescription instead of the generic that is available. Do I still have to pay the brand copay?
If you receive a brand drug when a generic equivalent is available you will be responsible for the generic copay plus the difference in cost between the brand and the generic drug. This is the case regardless of the reason that you use the brand name drug.
Question: What if I currently have a prescription for a drug that is subject to Step Therapy requirements?
Step Therapy means that you may need to use one medication before benefits for the use of another medication can be authorized. Your pharmacist will receive an electronic message sent to their computer at the point of sale notifying them that Step Therapy is required.
Step Therapy edits at the point-of-sale help:
- encourage manufacturer recommended and/or nationally recognized utilization of prescription benefits
- promote the use of recognized prescribing guidelines
- support access to high quality, yet cost-effective prescription drug benefits
In order to give you time to consult with your physician, Step Therapy requirements will not be applied until February 1, 2005. During January any medications you are currently taking that requires Step Therapy under the Anthem Prescription Management program will be approved for a refill per your existing prescription. After February 1, Step Therapy requirement will apply to any existing or new prescription that falls within the Step Therapy program. You will have to meet the program requirements in order for your prescription benefit to apply. Please refer to the Indiana University Overview booklet for a complete listing of drugs requiring Step Therapy.
Question: If I have refills left on a prescription for an amount greater than an approved Quantity Limit, what will happen when I request a refill?
A Quantity Limit is a limit on the amounts of a medication that you can obtain benefits for during a specific period of time. Most often, Quantity Limits are set on a monthly basis.
Effective January 1, 2005 your refill of medication will be subject to the Anthem Prescription Management Quantity Limit edits. Your physician may call 800-338-6180 or fax 800-601-4829 with a request for a review of the quantity of medication being filled.
Question: What if I don't agree with Anthem's determination of coverage related to Prior Authorization, Step Therapy, Quantity Limits, or other prescription coverage determinations?
Anthem maintains processes for complaints and appeals.You have the right to file a complaint or a formal appeal regarding Anthem's services, coverage, products etc. (please see your IU overview booklet for details)
You or your authorized representative may contact your health plan with a formal appeal request.
Question: How do I find out how much my prescription copay will be for a brand name drug?
For 2005, the copay levels will not change.
Customers are able to contact Anthem Prescription Customer Service to request a price quote on medications. Customer Service representatives are able to look up a drug on the Anthem Prescription Management system to help customers determine their applicable copayment.
Tier 1: Generic Drug or Brand with Generic Equivalent* $5 Retail $10 Mail
Tier 2: Brand Drug** $15 Retail $30 Mail
Tier 3: Brand Drug*** $30 Retail $60 Mail
Tier 4: Non-covered Drug w/ plan discount**** 100% Retail 100% Mail
* For brand with generic, customer pays generic copay and cost difference between brand and generic.
** Low-cost refers to prescriptions up to $60 retail for up to a 30-day supply (up to $180 mail order for up to a 90-day supply).
*** High-cost refers to prescriptions $60 or more for up to a 30-day supply ($180 or more mail order for up to a 90-day supply).
**** Tier 4 includes drugs that require a prescription by law, but are not covered under the Plan, for example, Viagra. The employee receives the benefit of the Plan's discount, but pays 100% of the discounted price of the prescription.
Question: What if I am going on vacation and need my prescription refilled early?
As a PPO plan participant, you have access to over 50,000 chain and independent retail pharmacy providers that participate in the Anthem Rx Pharmacy Network nationwide. If you use a national chain pharmacy, like Walmart, CVS, or Osco, in most cases, you will be able to obtain refills nationwide on prescriptions. When in need of a refill, present your new identification card, along with your prescription bottle to obtain a refill by only paying the applicable copayment at the time the prescription is received. Mail order prescriptions can also be mailed at almost any location in the United States.
If you wish to obtain an early refill, in general, you can obtain two (2) vacation early refills a year for each prescription. The amount of each early refill is only the amount of one regular refill (30 days retail; 90 days mail order) for each prescription. You will need to have your pharmacist call Anthem at the phone number on the back of your identification card 800-345-2460.
In the event that you need a refill for an extended leave, you must contact the University Human Resource Services office at 812-856-4642 for approval. Extended refills are normally only approved for purposes of overseas travel.
Question: What happens if my medication is not covered?
Even if your medication is not covered (for example, drugs for hair loss, Viagra or prescription antihistamine) you can still have your pharmacist process the prescription through your benefit plan in order to obtain the drug at 100% of the plan's discounted cost instead of the pharmacy retail price. In cases when the retail price is less than the contracted discount, you will be required to pay the lesser of the retail price, the pharmacy's usual and customary price, and the contracted price.
Question: How do I know how much money to send with my mail order, and what will happen if I send the wrong amount?
Under your PPO plan mail order benefit, you have the option of paying by credit card (including an IU TSB Card, if you elect this card through the IU TSB plan), check or money order. By using a credit card (or your IU TSB Card) you would be able to avoid a situation where too much or too little money is sent for prescriptions.
If you are unsure of the amount you will owe for a prescription you may contact Anthem Rx Direct Customer Service at 800-962-8192. For speech and hearing impaired assistance, call TTY (800) 221-6915.
Statements and envelopes are provided with your mail order medications. When a balance of $25 or less is due you will receive a balance due statement with your prescription order.
If you have a balance due of $25 or more, payment is required before your order will be processed for shipping. Anthem Prescription Management Customer Service will attempt to contact you to arrange for payment.
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