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PERS ODS Advantage PPORX pharmacy information

Formulary
The ODS Advantage Comprehensive Formulary includes generic and brand-name drugs. Generic drugs are listed in lower-case italics (e.g. furosemide) and brand drugs are in capital letters (e.g. CELEBREX) 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 ODS Advantage pharmacy member services.

You may request a hard copy comprehensive formulary (drugs by classification and an alphabetic list) by calling ODS Advantage pharmacy member services. 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.

ODS Advantage formulary updates will be made monthly. Changes are made based on new Part D-eligible drugs entering the market, drugs that were brand drugs being offered as generic drugs, FDA rulings that take a drug off of the market, FDA rulings that change the approved usages for drugs, Medicare rule changes, and ODS Advantage Pharmacy and Therapeutics Committee recommendations. These updates can result in a change in the cost share you pay for specific drugs. These updates can also result in drugs that were covered being excluded or once-excluded drugs now being covered. If you have any questions about the status of the drugs that you use, please call ODS Advantage pharmacy member services.

We offer additional coverage on some prescription drugs that are not normally covered in a Medicare prescription drug plan. Payments made for these drugs will not count toward your initial coverage limit or total out-of-pocket costs. To find out which drugs our plan covers, refer to your formulary.

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 or quantity limits. Current members may also be affected by changes in our formulary from one year to the next.

For each of the drugs that aren’t on our formulary or that have coverage restrictions or limits, we will cover a temporary 30-day supply (unless the prescription is written for fewer days) when a new or current member goes to a network pharmacy (and the drug is a Part D-eligible drug). After we cover the temporary 30-day supply, we generally will not pay for these drugs as part of our transition policy again. We will provide you with a written notice after we cover your temporary supply, explaining the steps you can take to satisfy the coverage restrictions or limits on the drugs you take.

If you are a resident or become a resident of a long-term care facility (such as a nursing home) or have a level of care change, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). If necessary, we will cover more than one refill of these drugs during the first 90 days after you enroll in our plan.

Generally, if you are taking a drug on our 2010 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2010 coverage year, except when a drug becomes an over-the-counter drug, when the drug is no longer eligible to be a Part D drug, or when new adverse information about the safety or effectiveness of a drug is released.

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
This form is used to request a coverage determination and a formulary exception request. Note: This form cannot be used to request barbiturates, benzodiazepines, 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 ODS.
Coverage determination form (physicians)
This form is used by the prescribing physician to request a coverage determination. A coverage determination includes a prior authorization, an exception request and an expedited review. This form cannot be used to request Medicare non-covered drugs including barbiturates, benzodiazepines, fertility drugs, drugs prescribed for weight loss, weight gain or hair growth, over-the-counter drugs or prescription vitamins (except prenatal vitamins and fluoride preparations).
Prescription drug redetermination request
This form is used to request an appeal or redetermination of a denied service or coverage determination. 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 a PA.

Prescription drug appeal and grievance procedure
What to do if you have a problem or concern — If you have a problem or concern, please refer to your Combined Annual Notice of Change — Evidence of Coverage for the PERS ODS Advantage PPORX Plan. This document 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 Combined Annual Notice of Changes — Evidence of Coverage for the PERS ODS Advantage PPORX Plan document provides more information.

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

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

You may also fax to: 800-207-8235

You can mail appeals, complaints and redeterminations to:

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

You may also fax to: 503-243-5105

For a report on the number of PERS ODS Advantage PPORX grievances, appeals and exceptions, call member services.

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.

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).

Pharmacy network
The ODS Advantage pharmacy network contracts with more than 600 pharmacies in the state of Oregon. PERS ODS Advantage PPORX has contracts with pharmacies that equal or exceed the CMS requirements for pharmacy access in your area.

ODS Advantage offers a wide range of choices when it comes to where and how you can order prescription drugs. The ODS Advantage pharmacy network includes retail, home infusion, long-term care and Indian health service pharmacies, and, for your convenience, a majority of national mail-order pharmacies. You can also fill up to a 90-day supply of maintenance medications at your local retail pharmacy.

The ODS Advantage Network pharmacy directory is available in a printable version for Oregon and Washington.

You must use network pharmacies to access your prescription drug benefit, except under non-routine circumstances when you cannot reasonably use network pharmacies. If you use an out-of-network pharmacy, you may need to pay for your prescriptions and mail your receipt to ODS Advantage 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 ODS Advantage Pharmacy member services.

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 member services 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.

We will cover your prescription at an out-of-network pharmacy if at least one of the following applies:

If you are unable to obtain a covered drug in a timely manner within our service area because there is no network pharmacy within a reasonable driving distance that provides 24-hour service.
If you are trying to fill a prescription drug that is not regularly stocked at an accessible network retail or mail-order pharmacy (including high-cost and unique drugs).
If you are getting a vaccine that is medically necessary but not covered by Medicare Part B and some covered drugs that are administered in your doctor's office.

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:

ODS 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 PERS ODS Advantage Pharmacy Customer Service at 888-786-7509 (TTY 800-433-6313) Monday through Friday, 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 Annual Notice of Changes and Evidence of Coverage or call member services for more information.

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

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.

The ODS Advantage Medication Therapy Management Program (MTMP)
We offer free medication therapy management programs for members who have multiple medical conditions, who are taking many prescription drugs, and who have high drug costs. These programs were developed by our team of pharmacists and doctors. We use these programs to provide better coverage for our members. For example, these programs help us make sure that our members are using appropriate drugs to treat their medical conditions and help us identify possible medication errors.

We invite members who meet specific criteria to participate in our medication therapy management programs. If you are selected to join a program, we will send you information about the specific program, including information about how to access the program. Remember, you do not need to pay anything extra to participate.

updated 10/2009
H3813-802
H3813_4006EGPPORX10A (11/2009)