Pharmacy FAQs

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. 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). Some pharmacies are excluded from coverage under the plan. Contact the Moda 360 Health Navigator team at 844-776-1594 for information.

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, brand, generic specialty and brand specialty 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).

Members can get up to a 90-day supply of non-specialty medications at either Postal Prescription Services (PPS) or 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.

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:

• Postal Prescription Services (PPS)
  • Phone number: 800-552-6694
  • ppsrx.com
• Costco Mail Order Pharmacy
  • Phone number: 800-607-6861
  • costco.com/home-delivery

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, 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.

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.

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.

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 ArrayRx Core network in the drop-down list within the 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). Some out-of-network pharmacies are excluded from coverage under the plan.

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. 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).

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 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.

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 at 844-776-1594.

Please call the Moda 360 Health Navigator team at 844-776-1594. Moda Health will work with your provider to get the necessary information to review the requested medication.

You can search Find Care, then select the ArrayRx Core network to find in-network pharmacies.

You can also call your Moda 360 Health Navigator team at 844-776-1594.

Yes. Specialty medications must be accessed through the exclusive specialty pharmacy. These prescriptions may be limited to a 30-day supply and require prior authorization. Members can get information about their plan's coverage and their out-of-pocket costs by selecting the "Pharmacy" tab in the Member Dashboard or by calling the Moda 360 Health Navigator team at 844-776-1594.

Specialty medications are often prescribed to treat complex chronic health conditions. They require special handling techniques, careful administration and an individualized ordering process. Details about our clinical services and a list of specialty medications can be accessed on the PEBB-specific Moda Health website, through the Member Dashboard, or by contacting the Moda 360 Health Navigator team at 844-776-1594.

Any new specialty drug approved by the Food and Drug Administration (FDA) is not covered until approved by Moda Health.

Ardon Health specialty pharmacy is the exclusive specialty pharmacy for PEBB members with Moda Health plans. Ardon Health can enroll you into its program over the phone, by contacting your physician for prescription information or by transferring an existing prescription from another pharmacy. To get started, contact your Health Navigator at 844-776-1594.

If you run out of your specialty medication before you can get set up with the exclusive specialty pharmacy, please call the Moda 360 Health Navigator team at 844-776-1594. A Health Navigator will work closely with you, your provider and the exclusive specialty pharmacy to get you the medication before you run out.

The specialty pharmacy will research financial assistance programs to see if there is any support available to you. If a program is identified, the pharmacy will work with you to apply for financial assistance.

When you schedule your order, you can pay by credit card, debit card or check. All payments must be made before the product is shipped.

If your medication is refrigerated, your order will be shipped via overnight delivery in special packaging to ensure the product remains refrigerated. If your medication does not require refrigeration, the exclusive specialty pharmacy will ship it to ensure it is delivered on the date the order is requested to be received.

The specialty pharmacy will also ship, with your order, any additional supplies you may need in order to administer your medication, such as syringes, alcohol swabs and sharps containers.

Your benefit authorizes up to a 30-day supply of most specialty medications. However, you may be able to receive up to a 90-day supply of certain specialty medications when allowed.

The Moda Health Specialty Drug Program provides payment for up to a 30-day supply of most specialty medications to avoid waste resulting from abrupt discontinuation. A medication can be discontinued for many reasons, including:

• Intolerable side effects
• Less-than-ideal results from the medication
• Dangerous changes in laboratory results