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OEBB OPDP

Pharmacy benefits

How do members access their plan’s pharmacy benefit?

Members need to show their Moda Health/OEBB ID card at a participating pharmacy and then the plan’s benefits will be applied at the point-of-service. If members do not use their ID card or if they fill prescriptions at a nonparticipating pharmacy, they can complete and submit an Rx claim form to request reimbursement from Moda Health. Reimbursement will be based on a “paid as calculated” basis (which means we will pay based on how the claim would have been paid if it had happened at a participating pharmacy).

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How can a member determine whether a specific medication is covered under the OEBB Pharmacy benefit plan?

Coverage for a medication is based on a plan’s design and the placement of the medication on the OEBB formulary. A formulary is a list of covered prescription drugs with options under the value, select generic, and preferred tiers. Each tier has a copayment amount and/or a coinsurance percentage. This represents the share of the cost that a member pays (the plan pays the other share). The formulary can be accessed on the OEBB-specific Moda Health member site under the Pharmacy tab or by logging into the Member Dashboard, myModa, and using the prescription price check tool.

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Why are changes sometimes made to how medications are covered?

Moda Health actively manages our members’ pharmacy benefits to ensure OEBB provides quality, comprehensive coverage and remains 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’s clinical team reviews the OEBB formulary and makes recommendations throughout the year. This allows Moda 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).

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Can a member get a 90-day supply of medications?

Members can obtain up to a 90-day supply of non-specialty medications at the mail-order pharmacy and at almost all retail pharmacies. Members need to make sure their prescription is written for up to a 90-day supply.

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How do members use Moda Health mail-order pharmacy?

To help in the planning process, members should be prepared to submit a new prescription for the medication they would like to have filled through the mail-order program.

The mail-order pharmacy available to OEBB members is:

Members should ask their doctor(s) for new prescriptions, written for up to a 90-day supply, with refills. These prescriptions should be mailed to the mail-order pharmacy with the completed order form, or a doctor can fax them (members should not send prescriptions unless they want them filled). Please allow seven to 10 business days for shipping.

Members must have their Moda Health/OEBB ID number (found on their Moda Health/OEBB ID card) to set up a mail-order account. To register, members log in to their Member Dashboard account, click on the Pharmacy tab, and then link to the PPS website.

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Once members’ mail-order pharmacy accounts and prescription(s) are established, how do they place orders for refills?

Members can order refills online through the pharmacy tab in their Member Dashboard account (which provides a link to PPS’s website), by mail or by telephone. Members must initiate refill orders; the mail-order pharmacy will not send them automatically.

If a prescription costs less than the copayment, does a member pay the total cost of the prescription or the copayment?

The member would pay the total cost of the prescription or the copayment, whichever is less. Members never pay more than the total cost of the prescription.

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If a member is traveling out of state, how does prescription drug coverage work?

Members have access to in-network benefits nationwide, as long as prescriptions are filled by a participating pharmacy. A list of participating pharmacies is available on the Moda Health website under Find Care. If members go to an out-of-network pharmacy, they must submit their claims and receipts to Moda Health for reimbursement. Members can obtain prescription drug claim forms online through the Member Dashboard. Reimbursement will be based on a “paid as calculated” basis (which means we will pay based on how the claim would have been paid if it had happened at a participating pharmacy).

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How do members submit a request for reimbursement under Moda Health OEBB Plans?

Members must complete the Rx Drug Claim Form. Forms can also be found online through myModa.

Submit claim forms to:
Moda Health
Attn: Pharmacy
P.O. Box 40168
Portland, OR 97240-0168

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If a member has dual pharmacy coverage and Moda Health is the secondary plan, how will the secondary claim be paid?

When the primary plan has approved and paid toward a pharmacy claim, Moda Health will pay up to what would have been covered had the claim been submitted to Moda for primary processing. Moda will not pay more on the secondary claim than a member’s total out-of-pocket expense on the primary claim.

In instances where the primary plan has denied 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 a primary claim.

Plans 1-5 pharmacy coordination of benefit examples:

  • Generic medication, 31-day supply dispensed, primary plan is not OEBB Moda Health, secondary plan is OEBB Moda Health Plan ($8 copay)
    • The member’s primary insurer pays on the claim, and the member’s copay/coinsurance is $20.
    • If the claim had been processed through OEBB Moda Health Plan as primary, the contracted rate would have been $15.
    • If OEBB Moda Health Plan had been primary, OEBB Moda Health Plan would have paid $7 toward the claim and the member would have had an $8 copay.
    • Because OEBB Moda Health Plan would have paid $7 as primary, the claim will pay up to $7 as secondary.
    • OEBB Moda Health Plan pays $7 toward the secondary claim, resulting in the member having an out-of-pocket balance of $13 after the primary and secondary insurance are billed.
  • Preferred brand medication, 31-day supply dispensed, primary plan is OEBB Moda Health Plan (25% up to a $75 max), secondary plan is Moda Health Plan (25% up to a $75 max)
    • The Moda Health contracted rate on the medication is $150.
    • As primary, Moda Health Plan pays $112.50, and the member’s remaining copay is $37.50.
    • If the claim had been processed under the secondary Moda Health Plan coverage, $112.50 would have been paid toward the claim and the member would have had a $37.50 copay.
    • Because Moda Health OEBB Plan would have paid $112.50, the claim will pay up to $112.50 as secondary.
    • OEBB Moda Health Plan pays $37.50 toward the secondary claim, resulting in the member having an out-of-pocket balance of $0 after the primary and secondary are billed.

Plans 6 or 7 pharmacy coordination of benefit examples:

  • Brand medication, 31-day supply dispensed, primary plan is not Moda, 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 Moda as primary, the contracted rate would have been $300. Assuming the deductible has been met, Moda would have paid $240, and the member would have had a $60 copay.
    • Because Moda would have paid $240 as primary, we will pay up to $240 toward the secondary claim.
    • Moda pays $200 toward the secondary claim, resulting in the member having a $0 out-of-pocket balance after the primary and secondary insurance are billed.

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If members receive a name-brand medication that has a generic formulation, what will they be responsible to pay?

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

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How will members know if their medications require prior authorization or have limitations?

The formulary can be accessed on the OEBB-specific Moda member website under the Pharmacy services tab or by logging in to the Member Dashboard and using the prescription price check tool. Please note that this list may change periodically. Members can also call Moda Health Pharmacy Customer Service at 866-923-0411.

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What should members do if their medication requires authorization?

If a medication is on the prescriptions requiring authorization list or if a member is taking a specialty medication or receiving a vaccination, the member should call Moda Health Pharmacy Customer Service. Moda Health will then work with the member’s provider to obtain the necessary information to review the requested medication.

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

For most covered medications, members pay a percentage of the cost. For value tier medications, members pay a fixed copayment or the cost of the medication (whichever is less). These costs count toward the member’s out-of-pocket maximum.

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