Pharmacy Benefit FAQ

If you should encounter any issues at a participating pharmacy, please contact the MedImpact customer contact center toll-free at 800.788.2949 or securely email MedImpact customer service at customerservice@medimpact.com to give a detailed explanation of the issue.

The formulary (a list of medications covered by Seton Healthcare Network Employee Health  Program) may be downloaded from the Medimpact Web site http://www.medimpact.com.  You may also contact MedImpact customer service at 1-800-788-2949.

Sign into the MedImpact web site at: http://www.medimpact.com. Once signed in, you can determine if a medication is covered by your pharmacy benefit by clicking on the Formulary Lookup.

Your pharmacy benefit may not cover all medications prescribed by your physician. Some medications may be excluded from coverage. Exclusions may include, but may not be limited to, over the counter (OTC) medications, nicotine smoking cessation products or any drug products used for cosmetic purposes.

To determine if a medication is covered by your pharmacy benefit, click on the Formulary Lookup link http://www.medimpact.com

Yes, your physician can help you save money, and reduce the administrative time it takes to change your prescription to a formulary medication from a non-formulary drug. To print a list of medications within a specific drug class, go to the MedImpact website http://www.medimpact.com and click on the Formulary Lookup link.

If you utilize Seton Health Plan benefit card when you obtain a medication, each drug is sent to the claims system and reviewed for any potential drug interactions based on your personal medication profile before your claim is approved.

Formulary drug addition requests may be submitted in writing by your physician to the Ascension Appeals and Grievance Dept. in St. Louis. An Ascension National Pharmacy and Therapeutics Committee (P&T Committee) reviews the requests and decide whether to add the medication to the formulary.

Oral contraceptives may be covered through the prior authorization (PA) process for medical necessity only. If you are currently taking an oral contraceptive that is not on the formulary list, you will be charged the non-formulary copay.

There are 2 leading non-sedating antihistamines (Claritin and Zyrtec) available without a prescription. Therefore, non-sedating antihistamines are excluded from the formulary. This was done primarily for the significant financial impact on the total pharmacy costs.

This term describes medications that range from illegal street drugs to medications with decreasing potential for abuse through. Prescriptions containing narcotics or amphetamines are often classified as controlled substances, since there is a relatively high potential for abuse or addiction.

If applicable, you can fill your prescriptions at Seton or retail pharmacy and mail order or a participating Choice90Rx pharmacy at the same time. The claims system reviews your personal medication profile each time you get a prescription filled to check for drug interactions, duplicate prescriptions, and other potential issues.

Depending on the type of medication, you can use more than one option to fill your prescriptions:

• For short-term (or acute) medications (i.e., antibiotics), use a Seton Pharmacy (DCMC, SMCW, SMCA) or participating retail pharmacy.
• For the greatest savings opportunities on medications you take on an ongoing basis (i.e., drugs for high blood pressure, arthritis, asthma, etc.), use a 90-day fill at a Seton pharmacy, mail order, or a participating Choice90Rx pharmacy.

Because of the unique role University Medical Center Brackenridge plays in providing services to patients who otherwise would not be able to afford healthcare services, the pharmacy at UMCB is able to purchase medications at prices below market price under a federal program nicknamed "340B." The UMCB Outpatient Pharmacy (OP), an extension of the hospital's inpatient pharmacy, passes those savings along to UMCB patients. This also means that if an associate is not a patient of UMCB, he or she cannot purchase prescription or over-the-counter (OTC) drugs at UMCB.

Days supply refers to the number of days of medication your physician prescribes. In most cases, your physician will prescribe up to a 30-day supply for short-term (or acute) medications and up to a 90-day supply for ongoing (or maintenance) medications.

When you sign in to the MedImpact website, you can access your pharmacy claims history by clicking on the PersonalHealthRx link located in the right-hand menu bar, enter the prescriptions report section, and select your criteria.

To view and print a summary of your annual pharmacy expenses for submission to a flexible spending account administrator or for tax reporting, go to the MedImpact website and click the PersonalHealthRx link located in the right-hand menu bar, enter the tax report section and select your criteria. There is an option for a printer friendly version at the top of the page that you can utilize to print a copy of the details.

Prior authorization is a process that evaluates a drug's prescribed use against a predetermined set of criteria to determine whether your plan sponsor will cover the medication. Note that if your physician has not submitted a prior authorization request, you will not have a prior authorization in the claims system.

If your physician has submitted a prior authorization and you would like to determine if the prior authorization is in the claims system, please contact the MedImpact customer contact center toll-free at 800.788.2949 or securely email Med Impact customer service at customerservice@medimpact.com.

In most cases, you will receive a letter stating a reason for the prior authorization or medical exception request denial. Under certain circumstances, you may have the right to appeal denial decisions. The letter will explain how to file an appeal to your plan sponsor.

Medications that require prior authorization (PA) are identified on the formulary with a "PA" after the drug name. MedImpact will be managing the PA process for all of the Ascension Healthcare Ministries. The process is as follows:

The prescribing physician will submit the PA request directly to MedImpact. Turnaround times are as follows:

• Phone calls - authorization decision made during the call
• Fax requests - within 48 hrs.

Physicians will receive a fax notification of the decision and employees will receive a written Coverage Notice informing them of the decision.

Prior authorizations that were approved in 2008 were electronically transferred to the new pharmacy benefit manager (MedImpact). As with any data transfer, errors may occur an in some cases it might be necessary to obtain another authorization from your physician.

MedImpact processes appeal requests in accordance with its Appeal policies and procedures, and in accordance with applicable state and/or federal statutes and regulations. MedImpact's appeal process consists of two levels of appeal for Clinical Appeals and a single level of appeal for Administrative Appeals. MedImpact's appeal process also provides for expedited review of Clinical Appeals and Administrative Appeals, as appropriate. A post-service appeal request is not considered urgent and is not processed as an expedited appeal. An Eligible Member/Member Representative may initiate an oral appeal by calling (800) 788-2949 or may submit an appeal in writing to the following address:

MedImpact Healthcare Systems Inc.
10680 Treena Street, 5th Floor
San Diego, CA 92131-2446
Attn: Appeals Coordinator

An Appeal Form is available and an Eligible Member may choose to complete this Form and submit to MedImpact to initiate an appeal.

All clinical appeal requests are reviewed by a Clinical Pharmacist Reviewer using Client-approved appropriate medical criteria and clinical guidelines. The Clinical Pharmacist Reviewer must not have been involved in the initial determination and is not the subordinate of the individual who made the initial decision. MedImpact may also utilize Clinical Peers to review clinical appeals and/or to provide additional or supporting medical review expertise. All denials of clinical appeals are rendered by a Clinical Pharmacist Reviewer/Clinical Peer.

When MedImpact is delegated to conduct Administrative Appeals on behalf of the Client, the Client must provide MedImpact with copies of all applicable Summary Plan Documents (SPD) upon delegation of the Administrative Appeal process, on an annual basis, and/or upon modification of the SPD.

An Eligible Member/Member's Representative is required to exhaust the first level of the Clinical Appeal process and Administrative Appeal process offered by MedImpact, prior to pursuing an external independent review or legal action under Section 502(a) of Employment Retirement Income Security Act of 1974 (ERISA) for the Appeal decision, as applicable.

For questions related to the appeal process or want to request an appeal packet, contact MedImpact’s Customer Service Department at 1-800-788-2949 (24/7).

Yes, on certain medications restrictions may include, but not be limited to, quantity limitations, age and gender specifications, prior authorization, or step therapy.

Yes, diabetic supplies are covered under both EPN and Expanded EPN. Glucose monitors (regardless of brand) are covered at $0 copayment (limited to one per year); if an additional monitor is required, the copayment is $15. Glucose test strips, lancets, syringes and insulin (any brand) have a $10 co-pay for a 30 day supply.

To obtain the best discount, consider using a Seton Network Outpatient Pharmacy or mail order. You’ll receive a 90 day supply for the cost of 2 copayments.

You save money by utilizing the Seton Network Outpatient Pharmacies (Seton Medical Center Austin, Dell Children's Medical Center of Central Texas, and Seton Medical Center Williamson), the Choice 90Rx Program or mail order.  You’ll receive a 90 day supply for the cost of 2 copayments.

The mail order drug program is administered by Medvantx. To find out more information about the mail order program please call Medvantx at 1-866-744-0621 or visit them on the web at www.medvantx.com.

Copayments are not prorated based on the number of days prescribed by your physician. If your doctor prescribed a medication for a period of less than 30 days (i.e., a 10-day course of antibiotics), you pay the full applicable copayment amount for 30 days. If the prescription is for more than 30 days, but less than 84 days, your pharmacy benefit may not apply. If your prescription is for 84 to 90 days, you pay the full applicable copayment amount for 90 days.

If you use mail order or the 90-day at retail program (Choice90Rx) and you take a medication on an ongoing basis, you’ll receive 90 days supply for the cost of 2 copayments.

Your pharmacy benefit may include coverage for certain products that are referred to as specialty medications. These specialty medications are prescribed to treat certain conditions, such as anemia, cancer, cystic fibrosis, growth hormone deficiency, hepatitis C, multiple sclerosis, and respiratory syncytial virus. Most specialty medications are injectables or require special shipping and handling, such as refrigeration. As a result, distribution of specialty medications and additional related services are arranged by specialty provider.

Injectable medications may be obtained through the Specialty Pharmacy Program (Coram Rx) or at one of the Seton Network Outpatient Pharmacies (Seton Medical Center Austin, Dell Children's Medical Center of Central Texas, Seton Medical Center Williamson). You may contact CoramRx at 1-877-426-7267 for more information.