Moda Health pharmacy FAQs
- How do I determine the cost (copay or coinsurance) of my medication?
- What is the Moda Health Preferred Drug List?
- Who makes decisions about drugs on the Moda Health Preferred Drug List?
- Is there a less expensive alternative to the medication I am taking?
- Why did the cost of my medication change?
- How will I know if my medication requires a prior authorization or if it has any limitations?
- Why does my medication require prior authorization?
- What should I do if my medication requires prior authorization?
- Are over-the-counter (OTC) products covered?
- If I receive a brand-name medication that has a generic equivalent available, what will I be responsible for paying?
- I have two prescription benefit plans and Moda Health is my secondary plan, how will my pharmacy claims be paid?
- Is there a mail-order pharmacy that I can use to fill my prescriptions?
- Am I required to access specialty medications (e.g., self-injectables, biologics, etc.) through an exclusive specialty pharmacy?
- What should I do if I need to fill a prescription but have not received an ID card?
- What is the Northwest Prescription Drug Program, OPDP and WPDP?
How do I determine the cost (copay or coinsurance) of my medication?
Moda Health provides the Preferred Drug List, as well as an online formulary look-up and price quote tool for members. You can access these resources by logging into the pharmacy section of your Member Dashboard account. The Moda Health Pharmacy Customer Service team is also available to answer any questions you may have pertaining to the cost of a medication.
What is the Moda Health Preferred Drug List?
The Moda Health Preferred Drug List is a listing of commonly prescribed medications and the associated tiering. Members and their doctors can choose between value tier, generic (tier 1), preferred (tier 2) or brand (tier 3) drugs. Each tier has a different copay amount and will depend on the member's benefit. Refer to your Member Handbook for specific tier and coverage information.
Who makes decisions about drugs on the Moda Health Preferred Drug List?
The list is developed and maintained by a committee comprised of doctors, pharmacists and other healthcare professionals called the Pharmacy and Therapeutics Committee. The committee makes decisions based on information about the drug's safety, effectiveness and associated clinical outcomes.
Is there a less expensive alternative to the medication I am taking?
There are many new generic medications on the market that are similar to brand name medications. The Preferred Drug List includes the names of many generic medications. Check with your doctor to see if there are opportunities for you to use generic medications in your treatment.
Why did the cost of my medication change?
At Moda Health, we take pride in actively managing your pharmacy benefits to ensure the 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 offers an open formulary that provides members with choice. Throughout the year, Moda Health's clinical team reviews our formulary and makes recommendations for program changes. This approach allows Moda Health to make changes when the Federal Drug Administration (FDA) approves new medications, when generic alternatives become available, or if changes occur to existing drug profiles (e.g. dosing, patient safety and/or approved uses).
Changes that occur are enforced in an effort to maintain a comprehensive benefit, provide members an open formulary and choice, while balancing the use of utilization management strategies to ensure the ongoing stability of the plan’s pharmacy program.
How will I know if my medication requires a prior authorization or if it has any limitations?
A listing of prescriptions requiring authorization is available under the benefits section of your Member Dashboard account. You may also call the Moda Health Pharmacy Customer Service team for more information.
Why does my medication require prior authorization?
Authorizations for medications ensure our members are receiving safe and most effective drug utilization through a thorough review by our clinical team, using evidence-based reviews of scientific studies, literature, and best healthcare practices. To initiate a prior authorization, please contact the Moda Health Pharmacy Customer Service team.
What should I do if my medication requires prior authorization?
If a medication that is being prescribed requires a prior authorization, call the Moda Health Pharmacy Customer Service team. Moda Health will work with your provider to obtain the necessary information for a review.
Are over-the-counter (OTC) products covered?
Medications federally designated as OTC are, in general, not covered under the prescription benefits (select diabetic supplies and insulin are covered).
If I receive a brand-name medication that has a generic equivalent available, what will I be responsible for paying?
If members request or their provider prescribes a brand-name drug when a generic equivalent is available, the member will be required to pay the brand copay or coinsurance, plus the difference in cost between the generic and brand-name medication.
I have two prescription benefit plans and Moda Health is my secondary plan, how will my pharmacy claims be paid?
When the primary plan approves a pharmacy claim and issues payment, the secondary plan will pay up to the amount Moda Health would have paid 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.
If a primary plan denies a claim or pays nothing toward a claim (e.g., the cost of the medication is less than the copay), the secondary plan will process the claim as if they were the primary plan.
Is there a mail-order pharmacy that I can use to fill my prescriptions?
Yes, Moda Health partners with exclusive mail-order pharmacies to offer members a 90-day supply delivered directly to the U.S. address of your choice. The participating mail-order pharmacy will depend upon the pharmacy network for your plan. To determine your plan’s mail-order pharmacy and obtain their contact information, please log in to the pharmacy section of Member Dashboard.
Am I required to access specialty medications (e.g., self-injectables, biologics, etc.) through an exclusive specialty pharmacy?
Yes, specialty medications must be accessed through the exclusive specialty pharmacy. The participating specialty pharmacy will depend upon the pharmacy network for your plan. To determine your plan’s specialty pharmacy and obtain their contact information please log in to the pharmacy section of Member Dashboard.
Specialty medications are limited to a 30-day supply and will require prior authorization. A listing of specialty medications is available through Member Dashboard or the member may also call the Moda Health Pharmacy Customer Service team for more information.
What should I do if I need to fill a prescription but have not received an ID card?
The pharmacy will need your unique Moda Health ID #, pharmacy BIN #, and pharmacy PCN #. You and/or your pharmacy may call the Moda Health Pharmacy Customer Service team to obtain the information necessary to process the claim.
What is the Northwest Prescription Drug Program, OPDP and WPDP?
The Oregon Prescription Drug Program (OPDP) joined the Washington Prescription Drug Program (WPDP) to combine purchasing power and formed the partnership “Northwest Prescription Drug Consortium”. Through the OPDP and WPDP, individuals living in Oregon or Washington may obtain a free discount card offering savings of up to 60 percent on generic medications and up to 20 percent on brand medications. You are an eligible individual for the Oregon or Washington Prescription Drug Program if you are:
- An Oregon or Washington resident, and
- You are uninsured or underinsured for prescription drug coverage
If you meet the criteria outlined above you are eligible to enroll in the program. There is no cost to enroll.Your Identification cards will be mailed to you within one week. To enroll:
- Call 1-800-913-4146, or
- Register online or print an application at the following website:
Oregon residents
Washington residents
Answers represent Moda Health standard benefits, for group specific details refer to your group's specific Member Handbook.
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