HEALTH BENEFITS REPORT
What the nullification of the OptumRx contract means to you
A few weeks ago, an appellate court released a 73-page opinion stating that the OptumRx contract that was awarded through state bid should be nullified. Obviously, our members in the SHBP are extremely concerned with this action and have several questions about the potential change.
In a nutshell, the suit was brought by Express Scripts International( ESI), which alleged that the award allowed an unfair advantage to OptumRx by allowing them to hedge their bets should the Design Committee make changes to the plan. Whether you agree or disagree with the decision, we have to prepare for the changes.
First and foremost, there will be no change to your current plan until at least January 1, 2019. If the Pharmacy Benefit Manager( PBM) Request for Proposal is presented and bid on, this would be the earliest that the state could facilitate the change.
The biggest concern for our members, should the PBM change again, is the change in the formulary, including the“ exclusionary” list that varies from one PBM to another. The change from ESI to OptumRx wreaked havoc with some of our members, as they had just adjusted to ESI’ s exclusionary list.
Essentially, the plan does not change outside of that, as the SHBP Design Committee sets the copays and coverage limits. Please know that we are closely following the rebid, and we will keep you apprised of any impending changes.
How to appeal the denial of your prescription
With the change of Pharmacy Benefit Managers for the State Health Benefits Plan, OptumRx has been strictly interpreting the State Prescription Plan in cases where for some reason, the previous PBM was filling prescriptions that should not have been covered. While many of you think that OptumRx is denying them for a financial gain for their company, they are actually doing what should have been done for several years.
I strongly suggest that all members of the SHBP Rx plan review the Prescription Drug Plans Member Guidebook on the SHBP website. Most of your questions can be answered through this publication, which was just updated in February. With regards to the formulary and excluded drugs, you can also find them on the SHBP site through OptumRx.
If your prescription is denied, I strongly suggest that you review pages 20 and 21 of the guidebook. I have included some information from the book here to assist you should you have an appeal.
Administrative Appeal *
An administrative appeal is one for which you believe benefits have been erroneously denied based on the plan’ s limitations and / or exclusions such as whether a particular drug is
covered or a dispensing limit applies for a certain drug. To file an administrative appeal you may call OptumRx Member Services at 1-844-368-8740( for active employees and non-Medicare-eligible retirees) or 1-844-368-8765( for Medicare-eligible retirees).
Required Information
For either type of appeal, please include the following information in your letter:
• Names and addresses of patient and employee;
• Your prescription drug plan identification number( on your prescription drug ID card);
• Your group number and group name as shown on your prescription drug ID card;
• Employer’ s name;
• Payment voucher number and date;
• Claim number, if available;
• Date the prescription was filled;
• Pharmacy’ s name;
• Name of the medication;
• Strength of the medication;
• Quantity prescribed;
• Prescription number;
• Amount billed; and
• Amount you paid.
If your drug claim has been denied and you think the claim should be reconsidered, appeals must be made within 12 months of the date you were first notified of the action being taken to deny your claim. When your appeal is received, the claim will be researched and reviewed. OptumRx will notify you in writing of the decision on your appeal within 60 days after the appeal is received. Special circumstances, such as delays by you or the provider in submitting necessary information, may require an extension of this 60-day period. The decision on the review will include the specific reason( s) for the decision and refer to specific provisions of the plan on which the decision is based.
External Review Procedures
After you have exhausted the OptumRx internal appeal process, if still dissatisfied, you can request an external review by an Independent Review Organization( IRO) as an additional level of appeal. Generally, to be eligible for an independent external review, you must exhaust the two-level internal appeal process, unless your claim and appeals were not reviewed in accordance with all of the legal requirements relating to pharmacy benefit claims and appeals or your appeal is urgent. In the case of an urgent appeal, you can submit your appeal in accordance with the identified process in the section“ Urgent External Review” on page 20 and also request an external independent review at the same time, or alternatively you can submit your urgent
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