Navigating health insurance benefits can be complex, especially when it comes to prescription drug coverage. PacificSource, a health plan provider, offers various plans with specific guidelines on what medications are covered. This article focuses on understanding PacificSource's coverage policies, particularly regarding weight loss drugs.
Accessing Your Plan Information
PacificSource provides several ways for members to access information about their benefits and manage their health.
- InTouch: Members can sign up for InTouch to securely access their plan benefits online, 24/7. This platform also offers tools and resources to support overall well-being.
Pharmacy Benefits under Legacy Plans
The following information pertains to pharmacy benefits, particularly within the Legacy plans offered by PacificSource:
- Legacy Apothecaries: Filling prescriptions at Legacy Apothecaries offers the advantage of obtaining a 90-day supply of medications for the cost of a 60-day supply. Most specialty pharmacy medications remain accessible through Legacy Apothecaries.
- Caremark Pharmacies: PacificSource utilizes Caremark pharmacies, a broad network that includes major chains like CVS, Walgreens, and Rite Aid, as well as many independent pharmacies. Members can check Caremark.com to confirm if their preferred pharmacy is in-network. A 90-day supply of maintenance medications can be obtained at one time through retail pharmacies, provided the prescription reflects a 90-day supply.
Weight Loss Drug Coverage
A key point to understand is that weight loss drugs are generally not a covered benefit under the Legacy plans. However, some manufacturers may offer drug cards to help cover the cost of these prescriptions, potentially reducing the out-of-pocket expense to a copay that doesn't run through your health plan initially. It’s important to be aware that these drug cards have expiration dates, and once they expire, the full cost of the medication becomes the member's responsibility.
Coverage for Diabetic Supplies and Medications
While weight loss drugs may not be covered, PacificSource does provide coverage for diabetic supplies under the pharmacy benefit. This includes items such as:
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- Meters
- Continuous glucose monitors (CGMs)
- Lancets
- Needles
- Syringes
It's important to note that some diabetic medications may no longer be on the drug list, so members should verify that their medications are still included. If a medication is no longer listed, members should contact their doctor to discuss alternative options.
Important Reminders Regarding Coverage
Several important points should be kept in mind regarding PacificSource's coverage policies:
- Over-the-Counter Medications: Over-the-counter medications are not covered unless they are prescription strength and prescribed by a provider.
- Compound Medications: Compound medications are covered only if similar drugs on the drug list are ineffective and the prescription has received prior authorization.
- Infertility Medications: A lifetime maximum applies to infertility medications, and a specified waiting period may be required for eligibility.
Legacy+ Network
Medical plans cover eligible services and supplies from Legacy+ network facilities for enrolled employees and dependents. All advanced imaging services must be provided at a Legacy Health facility. Out-of-network coverage is generally not covered, except for:
- Medically necessary covered services not available through the Legacy+ Network (prior authorization from PacificSource is required).
- Urgent and Emergency Care
- Diabetic supplies (also available through CVS Caremark)
Alternative care and imaging received out-of-network are not covered. If a provider is not a LabCorp laboratory provider, members should request a written order and take it to a LabCorp facility. Similarly, services like mammograms and advanced imaging (CT scans, MRIs, etc.) must be obtained at a Legacy facility.
Enhanced Drug List
The Enhanced Drug List is available to everyone on the LEHP+ plan. Certain drugs on this list are covered with a $5 copay, and most diabetic supplies are covered at 100%. This list is separate from preventive drugs covered under the Affordable Care Act.
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Utilization Management
PacificSource employs utilization management strategies for certain prescription drugs, which may include:
- Prior authorization requirements
- Quantity limits
- Step therapy protocols
Preventive Drug Lists
PacificSource offers several preventive drug lists that provide medications at no cost to members, aligning with the Affordable Care Act (ACA). These lists include:
- ACA Standard Preventive No-cost Drug List (CVS Caremark): This list contains medications mandated by the government to be available at no cost.
- PacificSource Expanded Preventive No-cost Drug List: Included in individual and small-group plans (and optional for large groups), this list covers listed drugs at 100 percent.
- Value Based Preventive No-cost Drug List: Offered to select self-funded groups, this list also covers listed drugs at 100 percent.
Specialty Medications and PrudentRx
Self-funded groups in Idaho, Oregon, and Montana may be eligible for a program with CVS Caremark and PrudentRx that lowers out-of-pocket costs for eligible specialty medications to $0. Members should check with their benefits administrator to confirm eligibility.
Incentive Drug List
An Incentive Drug List is offered to select large employer groups, which may include additional coverage requirements or limits.
Opioid Management
To combat the opioid epidemic, PacificSource is working to lower the total dose of opioids that members can receive per day, measured in Morphine Milligram Equivalent (MME).
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Drug List Updates
PacificSource Drug Lists are updated monthly, with notifications of changes provided to members 30 days in advance. A team of physicians and pharmacists regularly reviews and recommends changes based on the latest medical studies and FDA guidelines.
Information for Montana Members
For Montana members, psychiatric drugs on the drug list may not be subject to prior authorization if they are on the FDA shortage list at the beginning of the current quarter. Additionally, medications prescribed at the time of hospital discharge may be covered for 3 days without prior authorization.
Finding Your Drug List
Members can find their specific drug list on their member ID card. If there is no drug list on the ID card, the "Preferred (PDL)" list should be chosen. Non-members should choose the drug list for the state where they live or where their organization is headquartered for group coverage.
Requesting Exceptions
If a member cannot find a prescription drug on the formulary, they and their doctor have the right to request an exception by contacting Customer Service. Alternatively, the doctor can submit an exception request through InTouch or fax. Note that some plans may only cover certain drugs on the list, and a separate benefit may apply to some drugs, such as specialty drugs.
Additional Benefits
PacificSource also offers additional benefits such as a doula program for Legacy+ members, providing personal, nonmedical support during pregnancy, labor and birth, and the postpartum period.
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