Prescription Drug - Frequently Asked Questions
What are the major changes for 2014 for our prescription benefit (for those enrolled in the Riverside CareAdvantage PPO?
In 2014, we welcome Premier/MedImpact as our prescription drug administrator for those enrolled in the Riverside CareAdvantage PPO.
I already have a prescription with the Orchard mail order service. What do I need to do to continue receiving my medicine with the new mail order service?
You will need to get a new prescription to send to the new mail order pharmacy Postal Prescription Services (PPS). Contact information is listed below for PPS:
Postal Prescription Services (PPS) Mail Order Pharmaceutical Services:
What is step therapy?
A step therapy program is designed specifically for patients with certain conditions that require them to take medications regularly. It is the practice of beginning medication therapy for a medical condition with the most cost-effective medication and progressing to other more costly therapy(s) should the initial medication not provide adequate therapeutic benefit.
How does the step therapy program work?
In step therapy, medications are grouped into categories:
- Step 1 – First Line medications, mostly generic medications proven safe, effective, and affordable. These medications should be tried first.
- Step 2 – Second Line medications. In most cases, more costly brand name medications.
Step therapy is a process to ensure you are receiving a cost effective therapy. You will first try a recognized First Line medication (Step 1) before approval of a more costly and complex therapy is approved (Step 2). If the Step 1 therapy does not provide you with the therapeutic benefit desired, your physician may write a prescription for a Second Line medication. Generally, Second Line medications require the usage and failure of a First Line medication before coverage. The step therapy approach to care is a way to provide you with savings without compromising your quality of care.
Please call Premier/MedImpact for a complete list or for specific drug coverage questions. Please call Premier/MedImpact at (800) 910-1835 for specific drug coverage questions.
What are the major changes for 2014 for Riverside CareAdvantage Partner 340(b) Specialty Drug Program?
There are no major changes to the 340(b) Specialty Drug program. Specialty drug users will still be required to use Riverside Pharmacy Services for their specialty drug needs except for those drugs that cannot be purchased by Riverside Pharmacy Services.
How do I qualify for the Riverside CareAdvantage Partner Program, and the reduced or $0 co-pay (for those enrolled in the Riverside CareAdvantage PPO)?
Premier/MedImpact notifies Riverside of eligible members based on their current prescriptions. If a prescription is eligible, the team member will be contacted by Riverside with information on enrolling. You must be prescribed a medication covered under Riverside Premier/MedImpact plan. Please review your contact information in Employee Self Service (ESS) and update your phone number if needed so that we may contact you if you are eligible.
What are specialty medications?
Specialty medications are high cost drugs, which normally cost more than $600 per month, that are prescribed for chronic and complex conditions that often require complex therapies.
In terms of prescriptions with generic equivalents, who is responsible to get prior authorization if there is "research support" that a prescribed drug benefit is better than the generic drug?
Generics are therapeutically equivalent. If the member wants a brand based on the "research support," it would have to be substantiated medically by the physician and a prior authorization request from the physician would be required.
If the physician believes that the prescribed brand prescription is in the patient's interest, is prior authorization required?
What are the steps to obtain prior authorization?
If the physician wants the member to have a brand name medication, the physician needs to contact the Premier/MedImpact customer service at (800) 910-1835. There will be a prompt for a Physician Queue. A Medication Request Form (MRF) is available for the doctor to fill out stating the reason for the request. The completed MRF should be faxed to Premier/MedImpact at (858) 790-7100.
What card do I use to fill prescriptions (for those enrolled in the Riverside CareAdvantage PPO)?
You should use your separate Premier/MedImpact card to fill prescriptions.
Will I receive a new Premier/MedImpact ID card (for those enrolled in the Riverside CareAdvantage PPO)?
This year, all team members enrolled in the Riverside CareAdvantage PPO will receive new cards in late-December. If you have not received your Premier/MedImpact cards and your health insurance premiums are being deducted from your pay, you should first contact Premier/MedImpact at (need phone number) in order to verify your current address and to check to see if your cards have been sent.
How do I contact Premier/MedImpact (for those enrolled in the Riverside CareAdvantage PPO)?
You may call the Premier/MedImpact customer service starting Jan. 1, 2014, at (800) 910-1835 or online at http://mp.medimpact.com/PHI (24 hours a day). PPS (Postal Prescription Solution), your Mail Service Pharmacy, may be reached at (800) 552-6694 or online at www.ppsrx.com (24 hours a day).
What information will I need when I contact Premier/MedImpact (for those enrolled in the Riverside CareAdvantage PPO)?
You will need to provide the ID number from your Premier/MedImpact benefits card.
Will I be able to use my new Discovery Medical FSA debit card for my prescription drug purchases?
You may use your new Discovery Medical FSA debit card to pay for prescriptions at pharmacies that participate in Inventory Information Approval System (IIAS), which includes most major chain pharmacies. Some independent pharmacies may not participate. Please check with your pharmacist if you have questions.
What are the major prescription drug changes under Lumenos High Deductible Health Plan?
ExpressScripts will continue to provide prescription drug coverage under the Lumenos High Deductible Health Plan. There are no major changes for 2014.