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What to Do If the Pharmacy Says Your Prescription is Denied

JHMB

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Prescription drug coverage for PPO Plans A & B are administered through Elixir for employees, non-Medicare retirees, and their dependents. For Medicare-eligible retirees and Medicare-eligible dependents, prescription drug coverage is administered through Aetna®.

For more details on these plans (including tiers, copays, and contact information), please review the “Overview” section below. For details regarding the JHMB’s special program for maintenance medications, please select the “Rx90 Program” tab below. For details regarding the JHMB’s Select Formulary, please select the “Select Formulary ” tab below.

For questions, contact Elixir at the JHMB’s special customer service line: (833) 640-2849.

NOTE: The prescription drug coverage information provided in this section does not apply Plan C Kaiser participants. For information specific to Plan C participants, please visit the “Your Benefits” page.

Table of Contents:

Elixir – Formulary, Tiers & Copays


The Elixir plan has 4 tiers based on its current drug formulary (a list of prescriptions drugs covered by the plan). Elixir determines which drugs are placed on the formulary via its Pharmacy and Therapeutics Committee, which selects drugs from virtually all therapeutic types and bases its decisions upon factors such as – drug effectiveness, cost, quality, safety and potential side effects. The formulary is updated periodically as new drugs or new prescribing information becomes available.

The following is the list of the current Rx tiers and their respective 30-day/90-day copays:

  • – Tier 1 – Generic Drugs ($0/$0): Low-cost medications that are used for treating hyperlipidemia, hypertension, diabetes, and depression.
  • – Tier 2 – Generic Drugs ($10/$20): All other categories of covered, generic medications.
  • – Tier 3 – Preferred Brand-name Drugs ($35/$70): Covered drugs included on the formulary.
  • – Tier 4 – Non-preferred Brand-name Drugs ($50/$100): Covered drugs not included on the formulary.

Tier Exceptions: A copay exception may be available if you are taking a Tier 4 medication and your physician submits a Letter of Medical Necessity (LMN). The LMN is a letter from your physician to Elixir that sufficiently documents the reason(s) why you are unable to tolerate the Tier 3 medication. If Elixir authorizes the LMN exception, you will pay the Tier 3 copay instead of the Tier 4 copay.

“Dispense as Written” (DAW): Also, it is important to note that if you purchase a brand name prescription when there is a generic equivalent available, you will pay the brand copay plus the difference in cost between the brand name and the generic. However, should your physician indicate “Dispense as Written” on the brand name prescription and provide documentation showing that the brand name prescription is medically necessary, the cost difference penalty will be waived if authorized by Elixir.

NOTE REGARDING MAINTENANCE MEDICATIONS: For members taking maintenance prescriptions (such as a drug that is required to treat a chronic condition such as diabetes, high blood pressure, or high cholesterol) this program requires that you adhere to the Rx90 maintenance medication program. Please select the “Rx90 Program” tab above for more details.

What to Do If the Pharmacy Says Your Prescription is Denied

Did you know that there are four key steps you can take if a pharmacy denies your prescription? These four steps, along with information about maintenance medications, specialty medications, and common reasons for pharmacy denials, are included in a flyer we developed to help you understand and address prescription denials at the pharmacy.

We invite you to review this helpful resource and save it for the next time you experience an issue at the pharmacy. It’s just one of the ways we’re working to keep you informed and prepared to advocate for yourself and your health.

How to Address Issues/Questions Regarding Your Prescriptions

For assistance with your prescription drug benefit, please first contact the appropriate Elixir Customer Service phone number shown below based on your plan participation. If you feel that your issue is not being addressed appropriately, you may ask to speak with an Elixir Customer Service Supervisor. Should you feel that you require additional support beyond the Elixir supervisor, you may ask the supervisor to send an email to “FUSD Member Issues.” This process has been established to more effectively handle JHMB plan participant issues and concerns.

Elixir Participants: For assistance with your Elixir prescription drug benefit, please contact the Elixir Customer Service Help Desk at (833) 640-2849. The Help Desk is available to assist you with prescription questions 24 hours a day, 7 days a week.

Rx90 Program for Maintenance Medications

NOTE: This program does NOT apply to the Elixir Rx Plus Medicare Part D Prescription Plan or Plan C Kaiser Participants

Effective July 1, 2017, Elixir and the JHMB implemented Rx90, a maintenance drug program. For those Plan A and Plan B members taking maintenance prescriptions (such as a drug that is required to treat a chronic condition such as diabetes, high blood pressure, or high cholesterol) this program requires that you adhere to the following two steps to avoid paying the full cost of your maintenance medication(s):

  1. 1. Ensure your physician writes a prescription for any maintenance drugs to be filled in 90-day supplies (not 30), AND
  2. 2. You MUST use a pharmacy in the Rx90 Network for maintenance medications (Elixir Mail, Rite Aid, Walgreens or Costco retail pharmacy).

The plan does allow two (2) courtesy fills after July 1, 2017. Thereafter, all maintenance medication refills must be filled for a 90-day supply and at an Rx90 network pharmacy.

NOTE: Elixir Plus Prescription Drug Plan members do not need to have non-maintenance prescriptions filled within the Rx90 network; members can continue to fill non-maintenance prescriptions at any network pharmacy.

Download the FAQ for More Details

For more information about the Rx90 Program, please review the FAQ available by download below.

Elixir’s Select Formulary 

The Joint Health Management Board (JHMB) of the Fresno Unified School District continually looks for solutions to manage the rising cost of prescription medications. It is our goal to keep quality coverage affordable for members. After careful consideration, the JHMB approved the implementation of Elixir’s Select Formulary for Plan Options A and B effective January 1, 2018.

In 2016, the JHMB introduced 3 copay tiers for Generic Drugs ($10), Preferred Brand-name Drugs ($35), and Non-preferred Brand-name Drugs ($50). This original change was made in the interest of ensuring that our members have access to generic drugs and preferred brand-name drugs at affordable rates. In 2017, the JHMB added a fourth tier to provide members with access to low-cost generic drugs treating targeted health conditions (high cholesterol, high blood pressure, diabetes, and depression) at $0 copay. Each of these changes were made after careful consideration by the JHMB and its partners to manage the rising costs of prescription drugs while ensuring that our members have access to quality medications at affordable rates.

Under the Select Formulary program, the JHMB’s existing 4 copay tiers remain, however the drugs available within those tiers may change based on the latest Elixir standards.

How Elixir Determines its Select Formulary Drug List

A formulary is a list of prescriptions drugs covered by the plan. Elixir determines which drugs are placed on the formulary via its Pharmacy and Therapeutics Committee, which selects drugs from virtually all therapeutic types and bases its decisions upon factors such as – drug effectiveness, cost, quality, safety and potential side effects. The committee is composed of practicing physicians and pharmacists from a wide variety of medical specialties. The list is updated periodically as new drugs or new prescribing information becomes available.

What You Need to Do

In early November, Elixir will begin to send more detailed communications regarding which drugs are impacted by updates to the Select Formulary drug list. At that time, we recommend that you discuss the potential switch from a prescription on the exclusions list to a prescription on the approved list of alternatives with your healthcare provider. If your provider affirms that your use of the current prescription is medically necessary, then you or your provider may complete a request for prior authorization to continue receiving the medication after the annual formulary changes go into effect.

For More Information

Please be sure to look out for more information in the mail coming soon from Elixir. Until then, should you have additional questions regarding this upcoming change to your prescription drug benefit, please contact the Elixir Customer Service Help Desk at (833) 640-2849. The Help Desk is here to assist you with prescription questions 24 hours a day/7 days a week.

Download the FAQ for More Details

For more information about the Select Formulary, please review the FAQ available by download below.

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