Is my medication covered?
To see if a drug is covered by your specific plan, call our Customer Care Team at 1.800.591.6092.
What is a formulary?
A formulary is a list of Food and Drug Administration-approved prescription generic, brand-name and specialty medications. The formulary can be a useful resource in helping you and your physician choose effective medications that minimize your out-of-pocket expense.
Why can the formulary change during the year?
There are several reasons why the prescription drug list may change.
- New drugs are approved
- Existing drugs are removed from the market.
- Prescription drugs may become available over the counter
- Brand-name drugs lose patent protection and generic version become available.
Why isn’t my medication covered?
There are several reasons why a medication may not be covered:
- It is experimental or new
- Your doctor prescribed it for a use that is not recognized by the US Food and Drug Administration.
- It was given to you in a doctor’s office (example: a measles vaccine). Your medical plan may provide coverage.
- There are over-the-counter medications that work the same way.
You can buy any drug that your doctor prescribes, even if it is not covered by your plan. You will have to pay the full cost if the drug is not covered.
Are there any limitations on covered drugs?
Yes. Covered drugs are subject to plan limitations and exclusions. Some drugs may require prior authorization or step therapy. Other drugs may have a quantity limit which limits the amount of the drug covered for a specified time frame. The EnvisaCare Rx formulary lists whether a drug requires prior authorization or has a specific quantity limit.
How do I find out if I can take another drug in place of one that’s not covered?
Talk to your doctor about other possible drugs. You can also call our Concierge Customer Care Team at 1.800.591.6092.
What is prior authorization?
Prior authorization is a process to review a prescription drug for coverage before it is dispensed. This process is initiated by your doctor or other prescriber of the medication.
What is step therapy?
Step therapy is a form of prior authorization. Its purpose is to confirm if drugs generally considered “first-line” therapy based on clinical evidence have been tried first. If they have, the drug requiring step therapy will automatically be approved. In the event these drugs are not tried first, cannot be tried first or the drug is not part of Providence Health Plans claims history, prior authorization is required.
My prescription is for a drug that requires prior authorization. What do I need to do?
Talk to your doctor or other health care provider. You may wish to consider changing your prescription to an effective formulary alternative. Otherwise, your doctor or other health care provider can submit a prior authorization request.
I’ll be out of town for a while. How can I get an extra supply of my prescription medication?
When you know you’ll be away and may run out of your medication during your trip, you can request an extra supply before you go. Go to the pharmacy where you filled the original prescription. Your pharmacist may call EnvisaCare Rx for an exception that lets you get an early refill of your medication.
Where can I fill my prescription?
Your prescription drug benefit requires that you fill prescriptions at a participating pharmacy. You have access to more than 38,000 participating pharmacies and their services nationwide. Ask your local pharmacy if they accept your prescription benefits. You can also fill a prescription through our home delivery pharmacy partner, The Pharmacy at Bergheim.
Can I get a 90-day supply of medication at any pharmacy?
You may purchase up to a 90-day supply of maintenance drugs using a participating home-delivery pharmacy or a preferred retail pharmacy. Not all drugs are considered maintenance prescriptions, including compounded drugs, drugs from specialty pharmacies, and oncology drugs.
Can I get reimbursed for prescription medications I bought from a pharmacy that is not in EnvisaCare Rx’s network?
If you have out—of-network benefits, and you use a pharmacy that is not in the network, you pay the full amount at the time of purchase. Then you can get a claim and get reimbursed. You are still responsible for any copay or coinsurance. If you do not have out-of-network benefits, you will not be reimbursed. Call our Customer Care team to begin this process.
Why should I change to a generic medication?
The short answer is: because of the money you can save. The average annual patient savings with generic medications is over $200. This is why generic medicines account for over 80% of all prescriptions dispensed in the United States, yet only approximately 16% of all dollars spent on prescriptions. Generics are becoming the medication of choice because they can help save everyone money – your employer and most importantly, you.
Why did I receive a different prescription medication than my doctor originally prescribed?
Depending on the features of your employers benefit plan, your pharmacist may contact your doctor, after receiving your prescription, to request consideration of either a brand-name medicine from our preferred list or a generic version of your medicine. This may change the original prescription you received from your doctor and generally save you money.