OEBB OPDP

Pharmacy benefits

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

The coverage for medication is based on the OEBB selected plan design and the placement of the medication on the Moda Health or Oregon Prescription Drug Program (OPDP) formulary, which can be accessed on the Moda Health website or by logging into myModa and using the prescription price check tool under the pharmacy tab. The formulary is updated periodically.

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Why are changes sometimes made to how medications are covered?

At Moda Health, we take pride in actively managing our members’ pharmacy benefits to ensure that the OEBB programs provide quality, comprehensive coverage and remain current with industry standards and the changes occurring in the marketplace.

Moda Health considers the following when making changes to the pharmacy benefits:

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

Moda Health has a clinical team that reviews the OEBB formulary and makes recommendations for program changes throughout the benefit year. This approach allows Moda Health to make changes when the FDA has approved new medications, when generic alternatives become available or when changes occur to existing drug profiles (e.g., dosage recommendations, patient safety information or approved uses).

Changes are enforced as a way to maintain a comprehensive benefit and to provide OEBB members with an open formulary and choice, as well as to ensure the ongoing stability of OEBB’s pharmacy program.

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How do members establish their mail-order prescriptions with the Moda Health/OPDP mail-order program?

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.

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 order form, or a doctor can fax them. The mail-order pharmacies available to OEBB members include:

  • Postal Prescription Services (PPS)

Important notice: 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 simply log in to their myModa account and click on the pharmacy tab.

All valid prescriptions will be processed in accordance with plan provisions and will be subject to eligibility at the time the prescription is filled. Members will be charged for the required copayment. Members should not send prescriptions until they want them filled.

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

Members can order their prescription refill(s) online through the pharmacy tab in their personal myModa account, by mail or by telephone. Members must initiate refill orders; the mail-order pharmacy will not send them automatically.

To use the mail-order pharmacy, members can obtain a mail order pharmacy order form from the pharmacy tab of the myModa account. For assistance, members can contact Moda Health Pharmacy Customer Service at 503-265-2911 or 866-923-0411.

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If members order prescriptions through the mail-order pharmacy, how long will it take for the prescriptions to arrive?

Members should allow seven to 10 business days for shipping.

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Can I get a 90-day supply of medications?

Members can now get a 90-day supply at retail for Value and Select Generic tier medications. The copay for a 90-day supply at retail would equal 3 times the 31-day copay.

Members also have access to a 90-day supply through the mail-order benefit available through PPS/Kroger. The mail-order benefit can be used for Value, Select Generic Preferred Brand and Non-Preferred Brand tier medications. The copay at mail-order is 2 times the 31-day copay.

Make sure your prescription is written for up to a 90-day supply.

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If a 31-day supply of a preferred drug costs less than the copayment, do members pay the total cost of the prescription or the copayment?

Members would pay the actual 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 through one of the major participating chains. A list of participating pharmacies is available on the Moda Health website. If members go to a non-network pharmacy at anytime for any reason, they must submit their claim and receipts to Moda Health for reimbursement. Members can obtain prescription drug claim forms online through their myModa account. Reimbursement will be based on a “paid as calculated” measure (meaning we will pay based on the maximum allowable).

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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 be found online at www.modahealth.com/oebb through myModa.

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

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When and in what form are members reimbursed?

Moda Health will process claim requests and send reimbursements to the subscriber in the form of a check. Paper claims are processed on average within 10 business days, and checks are cut daily to ensure timely payment to our members.

Eligible prescription drugs purchased and paid in full by an enrollee will be reimbursed at the Moda Health/OPDP pharmacy contracted rate minus any required copayment or the maximum plan allowance minus the copayment, whichever is less. Standard OEBB benefit provisions apply.

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Are members required to submit the Prescription Drug Claim within a certain date span?

Yes. In no event, except absence of legal capacity, is a claim valid if submitted later than one year from the date of fill.

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If a member has dual pharmacy coverage, will Moda Health coordinate the pharmacy benefit?

Yes. There are two methods for processing coordination of benefits (COB) claims: electronic submission by the pharmacy or paper submission by the member mailing in a claim (more information is available in the Claims Procedures section of the Member Handbook). The ability for a pharmacy to participate can depend on the capabilities of the pharmacy’s claim submission software. If members are unable to have their secondary claim processed electronically, they can manually submit their claim to Moda Health for secondary processing by following the Claim Procedures Process outlined under the section of the handbook titled “Prescription Drug Plan Benefits.”

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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 Health for primary processing. Moda Health 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 (e.g., 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.

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 $50 max), secondary plan is Moda Health Plan (25% up to a $50 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.
  • Nonpreferred brand medication, 31-day supply dispensed, primary plan is not Moda Health OEBB, secondary plan is Moda Health Plan (50% up to $150 max)
    • 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 Health as primary, the contracted rate would have been $300. Moda Health would have paid $150, and the member would have had a $150 copay.
    • Because Moda Health would have paid $150 as primary, we will pay up to $150 toward the secondary claim.
    • Moda Health pays $150 toward the secondary claim, resulting in the member having a $50 out-of-pocket balance after the primary and secondary insurance are billed.

Major medical plan H coordination of benefit examples:

  • Brand medication, 31-day supply dispensed, primary plan is not Moda OEBB, secondary plan is Moda Plan H (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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Are compounded prescription drugs covered under the OEBB plans?

Compounded medications (containing at least one covered drug as an ingredient) are covered.

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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 formulation 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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Has the prescription out-of-pocket maximum changed?

Effective October 1, 2013 the annual out-of-pocket maximum will be replaced with a per prescription out-of-pocket maximum. This change was approved by the OEBB board in an effort to manage prescription cost over the course of the plan year, rather than have a large financial burden towards the beginning of the year for those who are taking brand or specialty medications.

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What applies toward the per prescription out-of-pocket maximum?

The per prescription out-of-pocket maximum includes the amount a member pays toward the covered expense on preferred-brand and non-preferred brand-name drugs. If members receive a brand-name medication that has a generic formulation available, the difference in cost between the brand-name and generic medication will not apply toward the per prescrption out-of-pocket maximum.

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

A list of prescriptions requiring authorization is available online under the benefits tab of myModa. Members also can call Moda Health Pharmacy Customer Service. Please note that this list may change periodically.

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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 medical Plan H, the HSA-compliant plan, work?

Moda Health and the Oregon Prescription Drug Program have contracted with pharmacies to provide members with a discounted price for prescriptions. A list of OPDP in-network pharmacies is available on the Moda Health website at www.modahealth.com/oebb.

Members will need to show their Moda Health ID card at a participating pharmacy and the benefits will be applied at the point of service. If members do not use their ID card or if they fill their prescriptions at a nonparticipating pharmacy, they are required to submit a claim form requesting reimbursement from Moda Health. Follow these steps to request reimbursement:

Complete the Prescription Drug Claim Form found online at www.modahealth.com/oebb, through myModa.

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