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Moda Health HMO (HMO-POS) pharmacy information

Formulary

The Moda Health Comprehensive Formulary includes generic and brand-name drugs. Generic drugs are listed in lower-case italics (e.g.valsartan) and brand drugs are in capital letters (e.g. VASCEPA) by therapeutic category, followed by an alphabetic list by drug name. We have not listed all strengths for all drugs. If you do not find your drug in the formulary, it may still be a covered drug. Please call Moda Health Pharmacy customer service.

You may request a hard copy comprehensive formulary (drugs by classification and an alphabetic list) by calling Moda Health customer service. Please note that this list may not include all of the changes that have been made this past year or be as up to date as the version on our website.

Transition policy

New members in our plan may be taking drugs that aren't on our formulary or that are subject to certain restrictions, such as prior authorizations, step therapy or quantity limits. Current members may also be affected by changes in our formulary from one year to the next.

Formulary updates

Most of the changes in drug coverage happen at the beginning of each year. However, during the year, Moda Health HMO (HMO-POS) may make many kinds of changes to the drug list. For example we may:

  • Add or remove drugs from the drug list. New drugs become available, including new generic drugs. Drugs get recalled and we decide not to cover it. We might remove a drug from the drug list because it is found to be ineffective.
  • Move a drug to a higher or lower cost sharing tier.
  • Add or remove a restriction on coverage for a drug.
  • Replace a brand name drug with a generic drug.

In almost all cases, we must get approval from Medicare for changes we make to the drug list.

If there is a change to coverage for a drug you are taking, we will send you a notice 60 days ahead of time or give you a 60 day refill at a network pharmacy.

  • During this 60 day period you should be working with your provider to switch to the generic or to a different drug that we cover.
  • Or you and your provider can ask us to make an exception and continue to cover the brand name drug for you.

Exception

An exception is a type of coverage determination that, if approved, allows you to obtain a Part D-eligible drug that is not on your plan sponsor’s formulary (a formulary exception). You may also request an exception if your plan sponsor requires you to try another drug before receiving the drug you are requesting, or the plan limits the quantity or dosage of the drug you are requesting (a formulary exception).

Coverage determination

Coverage determination is a decision from your Medicare drug plan about whether a drug prescribed for you is covered by the plan and the amount; if any, you are required to pay for the prescription. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn’t covered under your plan, that isn’t a coverage determination. You need to call or write to your plan to ask for a formal decision about the coverage if you disagree.

Pharmacy forms

  • Appointment of Representative
    This form is used to name a relative, friend, advocate or anyone else as your appointed representative. This person may request a coverage determination or file a grievance or appeal on your behalf. If you want someone to act for you, then you and that person must sign the Appointment of Representative form, giving the person legal permission to act as your appointed representative.
  • Coverage determination and exception request (members and providers)
    Use the link above to request a coverage determination and formulary exception request. This is a secure form and all member information is protected through this submission process. If you would prefer to fill out this form and send it in via mail or fax, you can download the coverage determination and exception request form and follow the instructions at the top of the form. Note: This form cannot be used to request fertility drugs, drugs for weight loss or weight gain, drugs for hair growth, over-the-counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations). If you are submitting a paper claim, please see the appropriate section below. You may print the pharmacy paper claim form, complete it, attach your receipt and mail it to Moda Health.
  • Prescription drug redetermination request
    Use the link above to request an appeal, or redetermination, of a denied service or coverage determination. This is a secure form and all member information is protected through this submission process. If you would prefer to fill out this form and send it in via mail or fax, you can download the prescription drug redetermination request form and follow the instructions at the top of the form. Note: You must receive a denied coverage determination before requesting a redetermination.
  • Prior authorization guidelines
    This document lists the prior authorization (PA) guidelines used to make a coverage determination for a drug noted in the comprehensive formulary with PA.
  • Step therapy guidelines
    This document lists the step therapy (ST) guidelines used to make a coverage determination for a drug noted in the comprehensive formulary with ST

Prescription drug appeal and grievance procedure

  • What to do if you have a problem or complaint — If you have a problem or complaint, please refer to your Evidence of Coverage for the Moda Health HMO (HMO-POS) plan, Chapter 9. This chapter covers how to ask for a coverage decision or make an appeal.
  • How to make a complaint about quality of care, waiting times, customer service, or other concerns — If you would like more information on how to make a complaint, your Evidence of Coverage for the Moda Health HMO (HMO-POS) plan document provides more information in Chapter 9.

If you have questions or need help with your appeal, coverage determination, exception request, redetermination or grievance, please call customer service. You can mail coverage determinations and exception requests to:

Moda Health Plan, Inc.
Attn: Moda Health Pharmacy Customer Service
P.O. Box 40327
Portland, OR 97240-0327

You may also fax to: 1-800-207-8235

You can mail appeals, complaints and redeterminations to:

Moda Health Plan, Inc.
Attn: Moda Health Medicare Appeals
P.O. Box 40384
Portland, OR 97240-0384

You may also fax to: 503-412-4003

For a report on the number of Moda Health HMO (HMO-POS) grievances, appeals and exceptions, call member services.

Pharmacy network

The Moda Health pharmacy network contracts with more than 600 pharmacies in the state of Oregon. Moda Health HMO (HMO-POS) has contracts with pharmacies that equal or exceed the CMS requirements for pharmacy access in your area. For your convenience, we contract with pharmacies throughout the U.S. and its territories.

Moda Health offers a wide range of choices when it comes to where and how you can order prescription drugs. The Moda Health pharmacy network includes retail, home infusion, long-term care and Indian health service pharmacies, specialty, and for your convenience, national mail-order pharmacies. You can also fill up to a 93-day supply of maintenance medications at your local retail pharmacy.

To find a Moda Health network pharmacy, you can search our online directory, Find Care. If you would like to request a printed version of our pharmacy directory, you can do so by sending an email to PharmacyMedicare@modahealth.com and we will send you a hard copy. Or, if you prefer, you can download the pharmacy directory yourself by clicking on the link below.

You must use network pharmacies to access your prescription drug benefit, except under non-routine circumstances when you cannot reasonably use network pharmacies. Quantity limitations and restrictions apply. If you use an out-of-network pharmacy, you may need to pay for your prescriptions and mail your receipt to Moda Health within 60 days of the fill date for processing. You will have to pay any difference between the out-of-network pharmacy's charge and the plan's allowable charge.

If you have any questions about access or mail-order services, or if you need help finding a pharmacy, please call Moda Health pharmacy customer service.

Out-of-network pharmacy access

Generally, we cover drugs filled at an out-of-network pharmacy only in limited, non-routine circumstances when a network pharmacy is not available. Before you fill your prescription in these situations, call customer service to see if there is a network pharmacy in your area where you can fill your prescription. If you do go to an out-of-network pharmacy for the reasons listed below, you may have to pay the full cost (rather than paying just your copayment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting your receipt. However, even after we reimburse you for our share of the cost, you may pay more for a drug purchased at an out-of-network pharmacy because the pharmacy's price is higher than what a network pharmacy would have charged. You should submit a claim to us if you fill a prescription at an out-of-network pharmacy. Any amount you pay, consistent with the circumstances listed above, will help you qualify for catastrophic coverage. To learn how to submit a paper claim, please refer to the paper claims process described next.

If you cannot use a network pharmacy, here are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:

  • Prescriptions related to care for a medical emergency or urgently needed care.
  • A network pharmacy is not within a reasonable driving distance that provides 24-hour service.
  • You are unable to fill a prescription that is not regularly stocked at an in-network retail or mail-order pharmacy (these drugs include orphan drugs or other specialty pharmaceuticals).
  • You are traveling outside of your plan service area and you run out of or lose your covered Part D drugs or become ill and need a covered Part D drug and cannot access a network pharmacy.
  • Note: Prescriptions filled at an out-of-network pharmacy in the situations listed above are limited to a 31-day supply.

How do I submit a paper claim?

When you go to a network pharmacy, your claim is automatically submitted to us by the pharmacy. However, if you go to an out-of-network pharmacy for one of the reasons listed above, the pharmacy may not be able to submit the claim directly to us. When that happens, you will have to pay the full cost of your prescription. Within 60 days of the fill date or when you return home (whichever is sooner), submit the receipt from the pharmacy with your name on it that lists the pharmacy, the phone number of the pharmacy, your member ID number, the prescription filled and the prescriber to the following address:

Moda Health Plan, Inc.
Attn: Pharmacy Claims
P.O. Box 40327
Portland, OR 97240-0327

You may print the pharmacy paper claim form, complete the form, attach your receipt and mail it to the above address.

If you have any questions about submitting your receipt, please call Moda Health Pharmacy Customer Service at 1-888-786-7509 (TTY users call 711) seven days a week, from 7 a.m. to 8 p.m., Pacific Time.

Upon receipt, we will make an initial coverage determination on the claim. Please refer to your Evidence of Coverage or call customer service for more information.

Moda Health pharmacy quality assurance

Moda Health has a number of quality assurance programs to ensure you are receiving the highest quality care and service at network pharmacies and by Moda Health.

We conduct drug utilization reviews for all of our members to make sure they are receiving safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribes their medications. We conduct drug utilization reviews each time you fill a prescription and on a regular basis by reviewing our records. During these reviews, we look for medication problems such as:

  • Possible medication errors
  • Duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition
  • Drugs that are inappropriate because of your age or gender
  • Possible harmful interactions between drugs you are taking
  • Drug allergies
  • Drug dosage errors

If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem.

Last updated October 1, 2016
Y0115_WEB_2017A Approved

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