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Pharmacy benefits

How can a member determine whether a specific medication is covered under the OEBB Pharmacy benefit plan?
Why are changes sometimes made to how medications are covered?
How do members establish their mail-order prescriptions with the ODS/OPDP mail-order program?
Once members’ accounts and prescription(s) are established, how do they place orders for refills?
If members order prescriptions through the mail-order program, how long will it take for the prescriptions to arrive?
If a 31-day supply of a preferred drug costs less than the copayment, do members pay the total cost of the prescription or the copayment?
If a member is traveling out of state, how does prescription drug coverage work?
How do members submit a request for reimbursement under ODS OEBB Plans A, B or C?
When and in what form are members reimbursed?
Are members required to submit the Prescription Drug Claim within a certain date span?
If a member has dual pharmacy coverage, will ODS coordinate the pharmacy benefit?
If a member has dual pharmacy coverage and ODS is the secondary plan, how will the secondary claim be paid?
Are compounded prescription drugs covered under the OEBB plans?
If members receive a name-brand medication that has a generic formulation, what will they be responsible to pay?
What applies toward the $1,000 plan-year out-of-pocket maximum?
How will members know if their medications require prior authorization or have limitations?
What should members do if their medication requires authorization?
How does medical Plan 9, the HSA-compliant plan, work?

How can a member determine whether a specific medication is covered under the OEBB Pharmacy benefit plan?

The coverage for medication is based on the OEBB selected plan design and the placement of the medication on the ODS or Oregon Prescription Drug Program (OPDP) formulary, which can be accessed on the ODS website or by logging into myODS and using the formulary look-up tool under the pharmacy tab. The formulary is updated periodically.

Why are changes sometimes made to how medications are covered?

At ODS, we take pride in actively managing our members’ pharmacy benefits to ensure that the OEBB programs provide quality, comprehensive coverage and remain current with industry standards and the changes occurring in the marketplace.

ODS 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?

ODS has a clinical team that reviews the OEBB formulary and makes recommendations for program changes throughout the benefit year. This approach allows ODS to make changes when the FDA has approved new medications, when generic alternatives become available or when changes occur to existing drug profiles (e.g., dosage recommendations, patient safety information or approved uses).

Changes are enforced as a way to maintain a comprehensive benefit and to provide OEBB members with an open formulary and choice, as well as to ensure the ongoing stability of OEBB’s pharmacy program.

How do members establish their mail-order prescriptions with the ODS/OPDP mail-order program?

To help in the planning process, members should be prepared to submit a new prescription for the medication they would like to have filled through the mail-order program.

Members should ask their doctor(s) for new prescriptions, written for up to a 90-day supply, with refills. These prescriptions should be mailed to the mail-order pharmacy with the order form, or a doctor can fax them. The mailorder pharmacies available to OEBB members include:

Postal Prescription Services (PPS)

Phone number: 800-552-6694
Order form

BioScrip (no longer available after March 31, 2012)

Phone number: 877-316-8921
Order form

Important notice: Members must have their ODS/OEBB ID number (found on their ODS/OEBB ID card) to set up a mail-order account. To register, members simply log in to their myODS account and click on the pharmacy tab.

All valid prescriptions will be processed in accordance with plan provisions and will be subject to eligibility at the time the prescription is filled. Members will be charged for the required copayment. Members should not send prescriptions until they want them filled.

Once members’ accounts and prescription(s) are established, how do they place orders for refills?

Members can order their prescription refill(s) online through the pharmacy tab in their personal myODS account, by mail or by telephone. Members must initiate refill orders; the mail-order pharmacy will not send them automatically.

To use the mail-order pharmacy, members can obtain a mail order pharmacy order form from the pharmacy tab of their myODS account. For assistance, members can contact ODS Pharmacy Customer Service at 503-265-2911 or 866-923-0411.

If members order prescriptions through the mail-order pharmacy, how long will it take for the prescriptions to arrive?

Members should allow seven to 10 business days for shipping.

If a 31-day supply of a preferred drug costs less than the copayment, do members pay the total cost of the prescription or the copayment?

Members would pay the actual cost of the prescription.

If a member is traveling out of state, how does prescription drug coverage work?

For Plans 3 through 8, members have access to in-network benefits nationwide, as long as prescriptions are filled through one of the major participating chains. A list of participating pharmacies is available on the ODS website. If members go to a non-network pharmacy at anytime for any reason, they must submit their claim and receipts to ODS for reimbursement. Members can obtain prescription drug claim forms online through their myODS account. Reimbursement will be based on a “paid as calculated” measure (meaning we will pay based on the maximum allowable).

How do members submit a request for reimbursement under ODS OEBB Plans A, B or C?

Members must complete the Rx Drug Claim Form. Forms can be found online at www.odscompanies.com/oebb through myODS.

Submit claim forms to:
ODS
Attn: Pharmacy
P.O. Box 40168
Portland, OR 97240-0168

When and in what form are members reimbursed?

ODS will process claim requests and send reimbursements to members in the form of a check. Paper claims are processed on average within 10 business days, and checks are cut daily to ensure timely payment to our members.

Eligible prescription drugs purchased and paid in full by an enrollee will be reimbursed at the ODS/OPDP pharmacy contracted rate minus any required copayment or the maximum plan allowance minus the copayment, whichever is less. Standard OEBB benefit provisions apply.

Are members required to submit the Prescription Drug Claim within a certain date span?

Yes. In no event, except absence of legal capacity, is a claim valid if submitted later than one year from the date of fill.

If a member has dual pharmacy coverage, will ODS coordinate the pharmacy benefit?

Yes. There are two methods for processing coordination of benefits (COB) claims: electronic submission by the pharmacy or paper submission by the member mailing in a claim (more information is available in the Claims Procedures section of the Member Handbook). The ability for a pharmacy to participate can depend on the capabilities of the pharmacy’s claim submission software. If members are unable to have their secondary claim processed electronically, they can manually submit their claim to ODS for secondary processing by following the Claim Procedures Process outlined under the section of the handbook titled “Prescription Drug Plan Benefits.”

If a member has dual pharmacy coverage and ODS is the secondary plan, how will the secondary claim be paid?

When the primary plan has approved and paid toward a pharmacy claim, ODS will pay up to what would have been covered had the claim been submitted to ODS for primary processing. ODS will not pay more on the secondary claim than a member’s total out-of-pocket expense on the primary claim.

In instances where the primary plan has denied the claim or paid nothing toward the claim (e.g., the cost of the medication is less than the copay), then the secondary plan will process the claim as if it is a primary claim.

Pharmacy coordination of benefit examples:

Generic medication, 31-day supply dispensed, primary plan is not OEBB ODS, secondary plan is OEBB ODS Plan A ($8 copay)

The member’s primary insurer pays on the claim, and the member’s copay/coinsurance is $20.
If the claim had been processed through OEBB ODS Plan A as primary, the contracted rate would have been $15.
If OEBB ODS Plan A had been primary, OEBB ODS Plan A would have paid $7 toward the claim and the member would have had an $8 copay.
Because OEBB ODS Plan A would have paid $7 as primary, the claim will pay up to $7 as secondary.
OEBB ODS Plan A pays $7 toward the secondary claim, resulting in the member having an out-of-pocket balance of $13 after the primary and secondary insurance are billed.

Preferred brand medication, 31-day supply dispensed, primary plan is OEBB ODS Plan B ($25 copay), secondary plan is ODS Plan B ($25 copay)

The ODS contracted rate on the medication is $150.
As primary, ODS Plan B pays $125, and the member’s remaining copay is $25.
If the claim had been processed under the secondary ODS Plan B coverage, $125 would have been paid toward the claim and the member would have had a $25 copay.
Because ODS OEBB Plan B would have paid $125, the claim will pay up to $125 as secondary.
OEBB ODS Plan B pays $25 toward the secondary claim, resulting in the member having an out-of-pocket balance of $0 after the primary and secondary are billed.

Nonpreferred brand medication, 31-day supply dispensed, primary plan is not ODS OEBB, secondary plan is ODS Plan B (50% copay)

The member’s primary plan pays, and the member’s remaining out-of-pocket expense is $200.
If the claim had been processed through ODS as primary, the contracted rate would have been $300. ODS would have paid $150, and the member would have had a $150 copay.
Because ODS would have paid $150 as primary, we will pay up to $150 toward the secondary claim.
ODS pays $150 toward the secondary claim, resulting in the member having a $50 out-of-pocket balance after the primary and secondary insurance are billed.

Are compounded prescription drugs covered under the OEBB plans?

Compounded medications (containing at least one covered drug as an ingredient) are covered.

If members receive a name-brand medication that has a generic formulation, what will they be responsible to pay?

If members request a brand-name drug or their provider prescribes a brand-name drug when an equivalent generic formulation is available, they will be required to pay the brand copayment or coinsurance, plus the difference in cost between the generic and brand-name medication.

What applies toward the plan-year out-of-pocket maximum?

The out-of-pocket maximum includes the amount a member pays toward the covered expense on generic, preferred-brand and nonpreferred brand-name drugs. If members receive a brand-name medication that has a generic formulation available, the difference in cost between the brand-name and generic medication will not apply toward the plan-year out-of-pocket maximum.

How will members know if their medications require prior authorization or have limitations?

A list of prescriptions requiring authorization is available online under the benefits tab of myODS. Members also can call ODS Pharmacy Customer Service. Please note that this list may change periodically.

What should members do if their medication requires authorization?

If a medication is on the prescriptions requiring authorization list or if a member is taking a specialty medication or receiving a vaccination, the member should call ODS Pharmacy Customer Service. ODS will then work with the member’s provider to obtain the necessary information to review the requested medication.

How does medical Plan 9, the HSA-compliant plan, work?

ODS and the Oregon Prescription Drug Program have contracted with pharmacies to provide members with a discounted price for prescriptions. A list of OPDP in-network pharmacies is available on the ODS website at www.odscompanies.com/oebb.

Members are responsible for paying the cost of their medications at the point of service. To receive the discounted price, members must go to an in-network pharmacy and present their ODS identification card to the pharmacist prior to having their prescription filled.

As long as OEBB members use their ODS identification card at an OPDP participating pharmacy, they are not required to submit receipts or a claim form to ODS for reimbursement. ODS will automatically track expenses that will accrue toward the member’s deductible and out-of-pocket maximum. In addition, ODS will reimburse members for eligible expenses under the prescription benefit.

If members do not use their ID card or if they fill their prescriptions at a nonparticipating pharmacy, they are required to submit a claim form requesting reimbursement from ODS. Follow these steps to request reimbursement:

Complete the Prescription Drug Claim Form for Major Medical plans found online at www.odscompanies.com/oebb, through myODS.