Pharmacy FAQ
- Why are prior authorizations required on certain drugs?
- How often can I refill my medication?
- I'm going on vacation and will need an extra supply of medication, what can I do?
- How does the mail order portion of my prescription benefit work and can I refill my prescription online?
- How do I get reimbursed for medications I have purchased at non-participating pharmacies?
- How are diabetic supplies covered under my prescription plan?
Why are prior authorizations required on certain drugs?
Some prescriptions require prior authorization for a number of different reasons:
- Drug Safety Concerns (especially with newly approved drugs)
There are a number of recent examples where a new drug was approved for use, entered the market and after more widespread use began showing harmful and even fatal patient side effects. Prior authorization criteria and procedures allow ODS to communicate and/or express any specific safety and drug use concerns to physicians prior to ODS payment for such medications. This is especially important for newly FDA approved drugs with a potential for such problems. - Determination of Medical Necessity
Prior authorization of certain drugs allows the physician to evaluate the patient's medication use and to provide documentation to ODS that explains the medical necessity of a specific drug. The prior authorization mechanism provides ODS with information, which documents the physician's actions and reasons for use of certain drugs, beyond the information contained on a prescription. In turn, this allows ODS to determine whether the medical necessity request for the drug meets the specific coverage criteria for that specific plan. - Direct to Consumer Advertising
Pharmaceutical manufacturers heavily advertise most new drugs. Patients may request and often demand certain prescriptions from their physicians that may not be approved for their specific indication. The ODS prior authorization procedure also provides a reduced pressure mechanism for a physician to deny a prescription for a patient for whom the physician does not think the prescription is appropriate or will not work and yet the patient demands the prescription. - Information Vehicle to Ensure Proper Administration of Drug Benefit
The prior authorization is a tool for ODS to receive information from the prescribing physician to ensure that employer - purchased drug coverage parameters are being met. - Managing Drug Program Costs
Prior authorizations are a way of managing plan costs on behalf of the employer. For example, it's a way of requiring the use of a less expensive medication (either generic, alternative brand or step therapy), prior to payment of a more expensive brand name medication. Often times, physicians are not aware of the price differences between different drugs and the prior authorization mechanism assists ODS members in getting the most cost effective medications. - Prior Authorization of Certain Medications does not Dictate Physician Prescribing and does not Diagnose Patients nor Practice Medicine
The prior authorization process is used to determine medical necessity, ensure patient safety and assist in administrating employer benefits appropriately.
How often can I refill my medication?
A medication can be refilled after 75% of the doses have been utilized. A special override can be put in place to allow for a refill by having the pharmacy telephone our customer service department. Examples of these cases are your medication has been lost, you are going on vacation, or your doctor has increased your dosage.
I'm going on vacation and will need an extra supply of medication, what can I do?
ODS also has participating pharmacies nationwide to enable members to use their benefit for any additional medications needed while on vacation. If your prescription refill will be due while you are away on vacation, a special override can be entered into the system to allow for the extra refill. Please allow extra time for your pharmacy to process your request. The member would be responsible for any additional copays that may apply.
How does the mail order portion of my prescription benefit work and can I refill my prescription online?
Members have the option of obtaining a 90 day supply per prescription for covered maintenance drugs through our mail order pharmacy, Certifax. To have Certifax fill your prescriptions you may use the special order forms available from your employer, ODS Customer Service or visit the Walgreens Healthcare Plus website (formerly Certifax). Prescription refills are also available.
How do I get reimbursed for medications I have purchased at non-participating pharmacies?
ODS has over 41,000 participating pharmacies located throughout the United States. However, in the rare case a participating pharmacy is not available, you will be required to pay full price for the medication and submit your receipt to ODS for reimbursement. A Prescription Reimbursement Claim form is available to download or from ODS Customer Service. Please mail claim form and attached prescription receipts to:
ODS
ATTN: Pharmacy Services
PO Box 40168
Portland, Oregon 97204
How are diabetic supplies covered under my prescription plan?
On all ODS prescription plans, insulin is a covered medication. Other diabetic supplies such as test strips, glucose tablets, disposable diabetic syringes and needles, may be covered under your plan, either as a medical supply or prescription item. Please refer to your Member Handbook for more details or contact Customer Service.