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General pharmacy FAQs

How do members access their plan's pharmacy benefit?

Members need to show their Moda Health/PEBB 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 an out-of-network pharmacy, they can complete and submit an Rx claim form to request reimbursement from Moda Health. For prescription claims filled before Jan. 1, 2022 please use this Form. For prescription claims filled on or after Jan. 1, 2022 please use this Form. 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 an in-network pharmacy).

How can a member know whether a specific medication is covered under the PEBB Pharmacy benefit plan?

Coverage for a medication is based on a plan's design and the placement of the medication on the PEBB formulary. A formulary is a list of covered prescription drugs with options under the value, generic, and brand tiers. Each tier has a copayment amount 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 PEBB-specific Moda Health member site under the Pharmacy services dropdown or by logging in to your Member Dashboard and selecting the Pharmacy tools in the Resources box.

Why are changes sometimes made to how medications are covered?

Moda Health actively manages its members' pharmacy benefits to ensure PEBB 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 pharmacy team reviews the PEBB 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).

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

Members can get up to a 90-day supply of non-specialty medications at either PPS or (effective Jan. 1, 2022) Costco mail-order pharmacies and at almost all retail pharmacies. Members need to make sure their prescriptions are written for up to a 90-day supply.

How do members use Moda Health mail-order pharmacy?

Members should submit a prescription for the medication they would like to have filled through the mail-order program. Members should not send prescriptions to the mail-order pharmacies unless they want them filled.

The mail-order pharmacies available to PEBB members are:

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. Please allow seven to 10 business days for shipping.

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

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 (which provides links to the mail-order pharmacies' websites), by mail or by telephone. Members can also go directly to a mail-order pharmacy's website. 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.

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 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 network in the drop-down search tool.

For pharmacies effective Jan. 1, 2022, members can select the 2022 NW Prescription Drug Consortium Core network in the drop-down search tool.

If members go to an out-of-network pharmacy, they must submit their claims and receipts for reimbursement. Members can get prescription drug claim forms online through their 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 an in-network pharmacy).

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

If members do not use their ID card or if they fill prescriptions at an out-of-network pharmacy, they can complete and submit a Prescription Drug Claim Form to request reimbursement from Moda Health.

For prescription drugs filled before Jan. 1, 2022, please use this Form. For prescription drugs filled on or after Jan. 1, 2022, please use this Form. 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 an in-network pharmacy).

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.

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 have to pay the brand copayment or coinsurance, plus the difference in cost between the generic and brand-name medication.

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

The formulary can be accessed on the PEBB-specific Moda Member website under the Pharmacy services tab or by logging in to your Member Dashboard and using the prescription price check tool. Please note that this list may change periodically. Members can also call the Moda 360 Health Navigator team (pharmacy customer service) at 844-776-1594

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, the member should call the Moda 360 Health Navigator team (pharmacy customer service). Moda Health will then work with the member's provider to get the necessary information to review the requested medication.

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