Washington FAQ
It’s only natural to have questions about your new plan and your new health carrier. If you can’t find the answer to your question here, please feel free to call our Customer Service Representatives.
General questions
Pharmacy questions
General
- What is myODS
- How can I find doctor or clinic in my network?
- How do I know what network I am in?
- How do I send in my claims?
- Can I see my claims online?
- Is there a Member Handbook I can access?
- How can I view my benefits?
- Do I pay ODS Health when I get a bill from my medical or dental provider?
- Can you help me understand the Explanation of Benefits (EOBs) I will be receiving?
What is myODS?As an ODS Health member, you have access to myODS, your personalized member website. With myODS, you can access health tools and resources to help you manage your health. To create your myODS account, please click on the “create an account” link in the myODS box on the right side of this screen. While in myODS, you can set your communication preferences for your EOBs. You can either receive EOBs electronically or through regular U.S. mail.
How can I find a doctor or clinic in my network?
Our interactive find care application lets you search for physicians and clinics by location, gender or language spoken. Once your ODS plan is effective, you can search the find care application using your subscriber ID so that all your results will be catered to your specific plan. For now, you can search the find care application as a guest. All results also show the network for each physician, dentist, pharmacist or clinic. As an ODS Health Washington member, your network is the First Choice Health PPO Washington and ODS Plus network. If you are searching for a Washington pharmacy, please use the WPDP network pharmacy locator.
How do I know what network I am in?
As an ODS Health Washington member, your network is the First Choice Health PPO Washington and ODS Plus network.
How do I send in my claims?
Once you receive treatment, if your doctor, pharmacist or facility does not bill ODS Health for you, please send your claims to:
Medical claims
ODS Health
P.O. Box 40384
Portland, OR 97240-0384
Please include the following information with your medical claim:
- Patient’s name, identification number and group ID number
- Date of treatment
- Diagnosis (medical only)
- An itemized description of services and charges
If the treatment is for an accidental injury, include a statement with the date, time, place and circumstances of the accident when you send us the physician or professional provider’s bill.
Pharmacy claims
ODS Health
P.O. Box 40168
Portland, OR 97240
To submit pharmacy claims, please fill out the pharmacy claims form.
Can I see my claims online?
Yes. Once your coverage with ODS Health is active, you can see your claims online through your personalized member website, myODS. myODS also allows you to manage your benefits and access health tools and resources. To register for myODS, visit the myODS registration page on or after your effective date of coverage.
Is there a Member Handbook I can access?
Yes. Once your coverage with ODS Health is active, you can access your Member Handbook, claims and benefit information, health tools, and other resources on myODS, your personalized member website. To register for myODS, visit the myODS registration page on or after your effective date of coverage.
How can I view my benefits?
Once your coverage with ODS Health is active, you can view your benefits and claims information and access health tools and resources on myODS, your personalized member website. To register for myODS, visit the myODS registration page on or after your effective date of coverage.
Do I pay ODS Health when I get a bill from my medical provider?
No. If you receive a bill from your medical provider, verify that your provider is billing you for the charges your health plan did not cover. Once you have confirmed the bill is for charges not covered by insurance, pay your provider directly.
Can you help me understand the Explanation of Benefits (EOBs) I will be receiving?
Yes. You can view sample medical EOBs, which include a glossary and explanation.
Pharmacy
- How will my medications be covered under ODS Health prescription benefits?
We recommend you view the ODS Preferred Drug List, available on our website or through myODS, your personalized member website. The ODS Preferred Drug List is a listing of commonly prescribed medications and the tiering of those medications under the ODS Health formulary. This PDL is a sample PDL, for the PDL for your specific plan, please log on to your myODS account and access your plan’s PDL. - How will I know if my medication requires a prior authorization or if it has any limitations?
You can view a listing of Prescriptions requiring authorization on our website and through myODS, your personalized member website. You may also call ODS Health Pharmacy Customer Service to inquire. - What should I do if my medication requires authorization?
If a medication that is being prescribed requires authorization, you should call ODS Health Pharmacy Customer Service. ODS Health will then work with your provider to obtain the necessary information to complete the review of the requested medication. - If my medication requires prior authorization, but I already had authorization in place with the previous carrier, will I need to start the process again?
Yes, a review by ODS Health is required. You should call ODS Pharmacy Customer Service to initiate the review process. - If I receive a brand-name medication that has a generic formulation, what will I be responsible for paying?
If you request, or if your provider prescribes a brand-name drug when an equivalent generic formulation is available, you will be required to pay the generic co-insurance, plus the difference in cost between the generic and brand-name medications. - If I have dual pharmacy coverage and ODS is the secondary plan, how will claims be paid?
When the primary plan has approved a pharmacy claim and paid towards that claim, the secondary plan will pay up to what would have been covered had the claim been submitted to ODS Health for primary processing. ODS Health will not pay more on the secondary claim than a member’s total out-of-pocket expense on the primary claim. - What is the Washington Prescription Drug Program (WPDP)?
The Washington Prescription Drug Program (WPDP) was created to pool eligible groups and individual purchasers of prescription drugs in an effort to negotiate lower prices which would, in turn, increase access to prescription drugs for both insured and uninsured Washingtonians. The WPDP joined the Oregon Prescription Drug Program in 2006 to form the Northwest Prescription Drug Consortium which created a larger pool to leverage even greater negotiating power for securing competitive administrative costs and transparent pharmacy benefit management services which lowers prescription drug costs for purchasers in both states. - How do I know what pharmacies are in the Washington Prescription Drug Program (WPDP) network?
A list of participating WPDP pharmacies can be found online through your myODS account. To view a list of participating pharmacies prior to your effective date, please visit the ODS Health participating pharmacy providers search tool.
- Is there a mail-order pharmacy I can use?
Members may use Postal Prescription Services (PPS). You may enroll by calling PPS at 800-552-6694. - How do I establish my mail-order prescriptions?
You should be prepared to submit a new prescription for the medication you would like to have filled through the mail-order program. - Am I required to access specialty medications (e.g., self-injectables, biologics, etc.) through an exclusive specialty pharmacy?
Yes. Specialty medications must be accessed through the exclusive specialty pharmacy, Diplomat Specialty Pharmacy. Each specialty prescription is limited to a 30 day supply and will require prior authorization by ODS Health. A listing of specialty medications is available on our website and through your myODS account. This specialty medication listing is a sample list, for the list for your specific plan, please log on to your myODS account and access your plan’s specialty medication list. To enroll with Diplomat call 877-534-7566.
- Why are changes sometimes made to how medications are covered?
At ODS Health, we take pride in actively managing our members’ pharmacy benefits to ensure that the programs provide quality, comprehensive coverage and remain current with industry standards and the changes occurring in the marketplace. ODS Health 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?
- If a 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.
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