Prescription Drug Plan Policies
We want to make sure your questions are answered and any concerns are met. We invite you to review our policies below. You can also contact us directly.
Policies
Out of Network Pharmacies
Filling prescriptions at a non-network pharmacy:
Traveling: If you are traveling within the United States and territories and become ill, lose or run out of your prescription drugs we will cover prescriptions that are filled at an out-of-network pharmacy. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a claim form. To learn how to submit a paper claim, please contact us at 1-888-462-2708, 7 days a week, 8:00 a.m. to 8:00 p.m., TTY/TDD users should call 1-800-471-7944.
You can also contact us to find out if there is a network pharmacy in the area where you are traveling. If there are no network pharmacies in that area, we may be able to make arrangements for you to get your prescriptions from an out-of-network pharmacy. We cannot pay for any prescriptions that are filled by pharmacies outside of the United States and territories, even for a medical emergency.
Emergencies: We will cover prescriptions that are filled at an out-of-network pharmacy if the prescriptions are related to care for a medical emergency or urgent care. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a paper claim form. To learn how to submit a paper claim, please contact us at 1-888-462-2708, 7 days a week, 8:00 a.m. to 8:00 p.m., TTY/TDD users should call 1-800-471-7944.
Other Situation: 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.
Before you fill your prescription in either of these situations, contact us 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 above, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a claim form. To learn how to submit a paper claim, please contact us at 1-888-462-2708, 7 days a week, 8:00 a.m. to 8:00 p.m., TTY/TDD users should call 1-800-471-7944.
Appeals, Grievances and Exceptions
Appeals: Physicians Choice Advantage + Rx provides all members with a meaningful process to appeal any Plan denial, referred to as an organizational determination, regarding the benefits a member is entitled to receive under Physicians Choice Advantage + Rx. If a service is denied, in whole or in part, you will be notified in writing of their appeal rights and are entitled to appeal the Plan decision. If you would like more information on the appeal process please contact us.
Grievances: Physicians Choice Advantage + Rx has a process for resolving grievances. A grievance is: any complaint, other than one involving a Plan decision/Organizational determination, expressing dissatisfaction with the way in which the Plan authorized representative, delegated entity or health plan provider delivers services to the member. You may make the grievance orally or in writing to the Plan, provider or facility. A grievance may also include a complaint that the Plan refused to expedite a request or an appeal. Grievances also include but are not limited to:
- Complaints regarding timeliness, appropriateness or access to health care services
- Quality of care received
- Quality of service received
For more information on grievances please contact us.
Reconsiderations: Physicians Choice Advantage + Rx has a process for reviewing reconsiderations. If the initial coverage determination is unfavorable, you may request a redetermination. For more information on reconsiderations contact us.
Plan Appeals Aggregate Report: You have the right as a Physicians Choice Advantage + Rx member to review the plans appeals, grievances, and exceptions report. To obtain an aggregate number of Physicians Choice Advantage + Rx grievances, appeals and exceptions please contact us.
Medical Management Policies
Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include:
Prior Authorization: Physicians Choice Advantage + Rx requires you to get prior authorization for certain drugs. (You may need prior authorization for drugs that are on the Formulary or drugs that are not on the Formulary and were approved for coverage through our exceptions process.) This means that you will need to get approval from Physicians Choice Advantage + Rx before you fill your prescriptions. If you don’t get approval, Physicians Choice Advantage + Rx may not cover the drug.
Step Therapy: In some cases, Physicians Choice Advantage + Rx requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Physicians Choice Advantage + Rx may not cover drug B unless you try Drug A first. If Drug A does not work for you, Physicians Choice Advantage + Rx will then cover Drug B.
Quantity Limits: Physicians Choice Advantage + Rx is interested in your health and safety. In some cases due to drug interactions, FDA requirements or the condition your specific drug treats Physicians Choice Advantage + Rx may place a limit on either the number of days supply or the quantity of certain drugs. You can find out if your drug has any additional requirements or limits by looking in the Formulary that begins on page 7.
You can ask Physicians Choice Advantage + Rx to make an exception to these restrictions or limits.