 Frequently Asked Questions
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
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).
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.
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?
RegenceRx encourages non-participating pharmacies
to bill us online, though they may decline. If the pharmacy
bills electronically, you should be charged the appropriate
amount at the time of purchase.
If the pharmacy does not bill us electronically, you’ll
pay the higher amount (cash price) for the prescription
at the time of purchase. Then 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?
You’ll need 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.
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.
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, you have a choice between PPS (Postal Prescription Service), a division of Fred Meyer/Kroeger, and 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 one
of the mail-order service providers. 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.
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 or if you have a PDA and would
like a downloadable FREE version of the preferred medication
list/formulary, one is available at www.ePocrates.com.
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).
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.
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 (888) 347-3416 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 (888) 456-7274.
Who do I call if I order medications and they are not delivered?
Contact Walgreens Customer Service at 1 (888) 347-3416. Walgreens Specialty hours of operation: Monday through Friday 5 a.m. - 5 p.m. Pacific time and Saturday 7 a.m. - 11 a.m. Pacific time.
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