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Frequently Asked Questions

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General FAQs

Preferred Medication Lists/Formulary FAQs

Getting Prescriptions Filled FAQs

Half-Tablet Program FAQs

RegenceRx Mail-Order Services FAQs

Generic Medication FAQs

Generic Incentive Program FAQs

Walgreens Specialty Pharmacy Services FAQs

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General FAQs

Why don’t you pay for over-the-counter medications?
Over-the-counter (OTC) medications and prescriptions containing OTC medications are generally not covered. OTC medications do not require a prescription and can be purchased at any pharmacy or grocery store. Although your doctor may write the name of an OTC medication on a prescription pad that does not make the medication a prescription drug and it is not available at your prescription copay. The exception to this is Prilosec-OTC™ which is considered a generic medication on our formulary. For coverage, Prilosec-OTC requires a doctor’s prescription and must be billed online by your pharmacy.

What is a quantity level limit? Why does RegenceRx restrict the amount of medication I can purchase at one time?
A quantity level limit is the maximum amount of one medication you may receive at one time. With your doctor’s prescription, you may purchase additional quantities of the medication at your own expense. Medications with quantity level limits are indicated by a “QL” after their names on the preferred medication list/formulary.

Reasons why a medication may have a quantity level limit include:

  • Contract use agreement.
  • Safety.
  • Potential for inappropriate use.
  • Lower-priced clinical alternatives available.
  • FDA-approved dosing regimen(s).
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Preferred Medication Lists/Formulary FAQs

What is a preferred medication list/formulary (PML) and how does a medication get added?
A preferred medication list/formulary (PML) is a list of generic and selected brand-name medications that is established, reviewed and updated routinely by an external group of physicians and pharmacists called the Pharmacy and Therapeutics Committee (P&T).

The criteria for evaluating and selecting medications are based on published scientific evidence and include:

  • Efficacy – A medicine’s ability to treat a condition or prevent a disease.
  • Safety – The incidence of side effects and drug interactions.
  • Outcomes – Select, higher-priced medications must provide additional documented clinical value or are typically excluded from the preferred medication list/formulary.

Do all non-preferred/non-formulary medications have alternatives?
There are thousands of drugs on our preferred medication list/formulary. So, many alternatives are available.

Why does my medication need “prior authorization” before RegenceRx will cover it?
Medications requiring “prior authorization” generally fall under one of the following categories:

  • Medications used for conditions that are contract exclusions, such as medications used for obesity or cosmetic purposes.
  • Medications with safety issues or a high potential for inappropriate use.
  • Medications with a much lower-priced clinical alternative.

What is step therapy? Why can’t I just take the medication my doctor prescribed?
Step therapy encourages you and your doctor to try lower-cost medications before moving to higher-priced alternatives. To ensure the appropriate use of medications and to help preserve our members’ health-care dollars, we believe this step-wise approach is a reasonable practice. That’s why we reserve for second or third choice those drugs that have not shown value over more cost-effective medications. For example, we may require you to try a generic medication before we may cover a non-formulary brand-name medication.

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Getting Prescriptions Filled FAQs

How do I use my prescription drug benefit through a pharmacy?
Simply present your member card to the pharmacist.

  • If you have a copayment plan, you’ll pay a designated dollar amount for each covered prescription at the time of purchase.
  • If you have a deductible plan, your deductible will be calculated automatically. Once the deductible is met, you pay only your copayment/coinsurance for covered prescriptions at the time of purchase.

How can I receive benefits if I have a prescription filled at a non-participating pharmacy?
Check your benefit booklet to determine if your health plan offers coverage for prescriptions filled at non-participating pharmacies. If the non-participating pharmacy bills electronically, you should be charged the appropriate amount at the time of purchase. We encourage non-participating pharmacies to bill us online, though they may decline.

If the pharmacy does not bill us electronically, you’ll pay the higher amount (cash price) for the prescription at the time of purchase. If your health plan offers coverage for non-participating pharmacies, you’ll need to complete a Prescription Medication Claim Form. Send the completed form along with your original receipts to the address on the form. You’ll be reimbursed as defined by your prescription benefit.

Do I need a claim form for each prescription filled at a non-participating pharmacy?
If your health plan offers coverage for non-participating pharmacies, you’ll need to submit separate claim forms for each individual (family member) and each pharmacy used. However, you can submit multiple prescriptions for the same member on one form.

What if I don’t have my member card with me when I go to the pharmacy?
The pharmacy may ask you to pay full retail charges for the prescription if they aren’t able to process your claim. In order to be reimbursed, send a completed Prescription Medication Claim Form, along with your original receipt(s) to the address listed on the form. You’ll be reimbursed as defined by your prescription benefit.

I lost my member card. How do I get a replacement?
Call our Member Customer Service phone number listed in your benefit brochure or contact us via e-mail.

Where do I get more claim forms?
Either print additional Prescription Medication Claim Forms here; contact your Employee Benefits Administrator, or call Member Customer Service at the phone number listed on the back of your member card.

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Half-Tablet Program FAQs

Why does RegenceRx offer a Half-Tablet Program?
Many medications come in different strengths that are all similarly priced. The Half-Tablet Program allows you to split some higher-strength tablets in half to save money on your copays.

When you receive a prescription for 34 tablets of one of the medications in this program (Celexa®, Lipitor®, Zocor® or Zoloft®) at the higher (double) strength, you can split the tablets for a 68-day supply. The advantage is that you make only one trip to the pharmacy every other month and you pay only one copay.

How do the tablets get split? Will my pharmacist split them or do I have to?
The pills in our Half-Tablet Program are easy to split, so it should not be difficult for you to split them. We will cover the cost of one pill splitter each year to help you with this process.

Have your pharmacist submit the cost of the pill splitter as a claim, just like a prescription medication. We will reimburse the pharmacy at no cost to you.

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RegenceRx Mail-Order Services FAQs

Why should I consider using one of the RegenceRx mail-order service providers?
If you have a mail-order benefit, you may want to consider the convenience of having your medication delivered to your home or office. Most members can receive up to a 90-day supply of their maintenance medication(s) for two to three copays depending on their specific prescription benefit.

Do I have a choice of companies providing mail-order service?
If you have a mail-order benefit, our designated mail-order provider is Walgreens Mail Service (Mail-Order Service).

Can anyone use the mail-order service?
Check your benefit brochure or call the number listed on the back of your member card if you aren’t sure whether you have a mail-order benefit. If you don’t have a mail-order benefit, you must fill your prescriptions at a participating pharmacy.

Can I purchase all my drugs through the mail-order service? Are there any limitations?
You can purchase most, but not all, medications from Walgreens Mail Service. You can receive up to the 90-day supply (or the maximum your benefit allows) if your doctor authorizes the quantity on your prescription.

Certain drugs are NOT available by mail order: Ambien®, Sonata®, Lovenox®, Fragmin®, Innohep®, Relenza®, Tamiflu®, Oxycontin® and self-injectable medications. The quantities of a few medications are limited both through mail order and at a retail pharmacy (see the “QL” indicator on the formulary). Other medications that are liquid or require refrigeration, for example, may not ship easily and can be restricted.

What is the difference between a mail-order service provider and Walgreens Specialty, the specialty injectables provider?
While both Walgreens Specialty and mail-order service providers will ship your prescription to you, Walgreens Specialty specializes in self-injectables and medications injected in a physician’s office.

Specialty injectables are limited to a 30-day supply per copay and should be obtained from Walgreens Specialty.

How will members be notified about the change of mail-service providers?
Members with a history of mail order use at PPS will be mailed a letter notifying them of the change approximately 30 to 45 days prior to the transition. The letter will contain information on how to enroll with Walgreens Mail Service.

Members who have a prescription that cannot be transferred (i.e. controlled substances, compounds, or expired prescriptions) will receive a letter with instructions on how to get a new prescription from their providers and enroll with Walgreens Mail Service.

A reminder letter will be sent to members who have not completed their enrollment with Walgreens Mail Service approximately 15 days prior to the transition date.

What steps do members need to take to change to Walgreens Mail Service?
If members are currently using PPS Mail Service and have any medication refills remaining, active, valid prescriptions will be transferred to Walgreens Mail Service on their behalf after the member has enrolled with Walgreens Mail Service. When they are enrolled and their prescriptions have been transferred, members need to call Walgreens to request their initial fill.

Please note: Certain types of medication refills cannot be transferred and require a new prescription. These include (1) compound medications; (2) controlled substances; (3) expired prescriptions; (4) prescriptions without remaining refills; and (5) future-fill prescriptions that have not been processed by PPS and are being held for a future date. Members who have a prescription or refill that cannot be transferred will need to request new prescriptions from their physicians and submit them to Walgreens Mail Service with the enrollment form.                                 

Will members’ copay or coinsurance change?
The member's benefit design will not change based on the mail service transition. 

Members paying a flat copayment will not see any change in their copayment.

Members with coinsurance, however, may see a fluctuation in their out-of-pocket expenses. While the coinsurance percentage will remain the same, it could be affected by increases in the actual costs of the medication. Reasons for these increases could include but are not limited to: a change in the price of a medication by the pharmaceutical manufacturer, or a change in the prescription being filled (i.e. quantity, strength, generic product, etc.).

Why are you transitioning to a large national chain instead of staying with a local company?
We have been pleased to work with Postal Prescription Service (PPS) as a partner. It has provided excellent service to our members and we thank PPS for all it has done to support our members.

As good stewards of our members' money, we make every effort to offer improved overall healthcare outcomes as well as the lowest net cost for their prescription medications. Our new agreement with Walgreens provides a positive long-term opportunity for our members and groups to experience the benefit of lower net costs for their prescription medications.        

Do members who use retail pharmacies have to transition to Walgreens Mail Service?
We are not changing our retail pharmacy network and members can continue to use any participating retail pharmacies for their prescription needs.

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Generic Medication FAQs

What is the difference between a generic and a brand-name medication?
Not much, except for the name and price. The products contain the same active ingredients. Generics, however, may cost between 20 to 60 percent less than the cost of the brand-name medication.

Why do generic and brand-name medications have different names?
Generic medications are called by their chemical name, while brand names are assigned by the manufacturer.

Are new brand-name medications better than older generics? Aren’t generic medications inferior?
Many new medications come to the market annually; however, new does not always equate to better. In many situations, generics remain first line and the medications of choice. Also, generics have a longer safety record than newer medications.

Finally, price does NOT reflect quality for generic or brand-name medications. Since generic medications generally sell for less than brand-name medications, they are falsely considered inferior to their brand-name counterparts.

Do all brand-name medications have generic equivalents?
No. Some drugs are protected by patent and are manufactured by only one company. Generic versions are available only after the patent expires (in about 20 years), and often at a lower price.

Occasionally, the original manufacturer of the brand-name medication launches legal challenges at the end of the patent, trying to block generic versions and extend the patent life of the brand name.

Current estimates suggest that about half the drugs on the market are available in a generic form.

Does the FDA review and approve generics for market the same way they do for brand-name medications?
Yes. Before the FDA will approve a generic for distribution, it must be generically and therapeutically equivalent to the brand-name counterpart. That means it must:

  • Have the same active ingredients, strength, and dosage form (tablet, liquid, injection, etc).
  • Meet FDA specifications for quality, purity and potency for the approved indications and conditions of use.
Generics and brand-names may differ, however, in some characteristics such as color, flavor, size and shape.

How can I get a generic medication?
Request the generic medication when speaking with your doctor about your prescription(s). It’s always a good idea to remind your pharmacist that you want the generic rather than the brand-name medication before they fill your prescription.

Is my generic medication on the preferred medication list/formulary? How can I tell which medications are generic?
Generic drugs are in lower-case letters. Brand-name drugs start with a capital letter and are followed by a ®.

Please note: When looking at our formulary, generic drug names will be followed by a brand name in parentheses. The brand name is there only as a reference and is not available on the formulary.

How can I get a copy of the preferred medication list/formulary to take to my next doctor appointment?
You can either view or print a copy of your preferred medication list/formulary.

Will I save money by using generic medications?
If you’re on a tiered plan (if you pay different copays for different kinds of drugs), you save money when you purchase generic drugs. That’s because the copay for generics is your lowest pharmacy copay.
With brand-name medications, you end up paying higher copays now AND higher health-coverage rates in the long term. There is a direct cost savings to you, your employer and your health plan when you use generic medications.

Where can I find more information about generic drugs?
The FDA provides information about all approved medications on its Web site at www.fda.gov/cder/consumerinfo/default.htm.

Another source of specific drug information on thousands of prescription and over-the-counter medications is available through the MEDLINEplus Health Information Web site (a service of the U.S. National Library and the National Institutes of Health).

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Generic Incentive Program FAQs

Who is eligible for the RegenceRx Generic Incentive Program?

  • Regence BlueShield and Asuris Northwest Health members with prescription benefits who are currently taking one or more of the selected brand medications are eligible for the generic incentive program starting May 17, 2005.
  • Members who are starting therapy on the generic alternative and have no prior claims history for the specified medication within the last six months are eligible.

Who is excluded from the RegenceRx Generic Incentive Program?
Regence and Asuris members without traditional prescription coverage, including all vendor auto-pay programs, Health Saving Accounts and discount plans.

On discount plans, members receive a discount on their medication price by presenting their insurance card, yet they have no pharmacy benefit, e.g., Medicare Supplement members. These members pay 100 percent of the discounted price.

Is a member eligible to receive the incentive more than once?
A member may only receive the incentive for a particular drug once. For example, if a member takes Nexium® and switches to Prilosec OTC™, they can receive a one-month supply of Prilosec OTC at no charge, one time only. However, the same member is eligible to receive the incentive on a different drug if, for example, they were switching from Altace® to lisinopril.

Can the member receive the incentive via mail order?
No, the program is offered at the retail level only. Also, paper claims are not eligible for the program. The program is adjudicated electronically and therefore must be received by electronic transmission.

How many days supply is the member eligible for?
A member is eligible for up to a 30-day supply. Members with greater than a 30-day benefit may only have a zero-dollar copay on the first 30 days worth of medication. The member may then refill their prescription for their usual days supply and receive it at their generic copay.

What medications are eligible for the incentive?
Only about 20 generic alternatives (specifically oral tablets/capsules) are eligible for the incentive program. View list of eligible medications. Over-the-counter (OTC) medications are excluded from the program, with the exception of Prilosec OTC.

And what about Prilosec OTC? It’s not available in a 30-day supply.
A member may receive up to a 14-, 28-, or 42-quantity package of Prilosec OTC at no charge.

How would a prescription be processed to receive the generic alternative at no charge?
Prescriptions are processed as any other prescription. If the member is eligible for the incentive, the claim will result in a zero-dollar copay.

Can a member submit a paper claim for the incentive?
No, the claim must be submitted electronically. If the generic alternative prescription is processed initially as a paper claim, the member will no longer be eligible for the program.

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Walgreens Specialty Pharmacy Services FAQs

Who can participate in the RegenceRx Specialty and Injectable Medication Program with Walgreens Specialty?
Participation in this new program is available for all Regence members and providers.

What medications can I order from Walgreens Specialty?
A list of medications that may be ordered from Walgreens Specialty can be found on the RegenceRx website at www.regencerx.com/programs/walgreens/member-index.html.

Please contact Walgreens Customer Service at 1-855-248-2468 to inquire about medications not listed.

How many doses may be ordered at a time?
Usually one dispensing, or a month supply of medication is the maximum allowed.  However, your doctor can indicate refills on the Request Form, and Walgreens Specialty will contact you to coordinate future delivery of refills.

What is the cut-off time for placing orders?
Orders may be placed up to 5 p.m. Pacific time, Monday through Friday, and until 11 a.m. Pacific time on Saturday.  When placing an order less than 1 hour prior to the cut-off time, you must indicate if “URGENT” next-day delivery is required.  Note that when ordering drugs on a Saturday, the earliest delivery is Monday morning for urgent orders and Tuesday for non-urgent orders.

What qualifies as an urgent order?
An order would be classified as urgent if failure to obtain the drug by the following business day could potentially jeopardize the health of the patient, result in patient hospitalization or emergency room visits.

How are urgent orders handled?
Urgent orders will be shipped via overnight service.  For special urgent order handling, please contact Walgreens Customer Service at 1-855-248-2468.

Who do I call if I order medications and they are not delivered?
Contact Walgreens Customer Service at 1-855-248-2468.  Walgreens Specialty hours of operation: Monday through Friday 7 a.m. - 7 p.m. Pacific time and Saturday 6 a.m. - 2 p.m. Pacific time. Closed on Sunday.