Pharmacy Services

Pharmacy Services from MedImpact & Commcare Specialty

MedImpactMedImpact Healthcare Systems manages pharmacy benefits for Prominence Health Plan (PHP) members. Member-specific pharmacy copay information can be found on the front your member ID card.

MedImpact Pharmacy Processing Information
BIN = 003585
PCN = ASPROD1
Group = UPH

 

Specialty Pharmacy Care

A specialty pharmacy program supports patients with complex health conditions who need injectable medications, or medications with strict compliance requirements or special storage needs.

commCare_logo_full_color_horiz_400Prominence Health Plan partners with Commcare Specialty Pharmacy for Specialty Pharmacy Services. Commcare will continue to provide your specialty medications via delivery to your home, workplace, physician’s office, or other designated location.

Specialty Pharmacy Drug List >

Get more information about Specialty Pharmacy >

Pharmacy by Mail Program

The pharmacy mail order program is administered by MedImpact Direct. PHP members can obtain a 90-day supply for ongoing medication(s) and you can save money and time by having prescriptions for maintenance medication(s) delivered right to your home.

Get more information about MedImpact Direct Pharmacy by Mail >

Pharmacy Forms

For a complete set of pharmacy forms including the MedImpact claim form and registration for the pharmacy by mail program through MedImpact Direct, visit the General Forms and Resource page.

Drug Exception Process

How do I request an exception to the Prominence Health Plan Formulary?

You can ask us to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

  • You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.
  • You can ask us to cover a formulary drug at a lower cost-sharing level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug.
  • You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, we limit the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, Prominence Health Plan will only approve your request for an exception if the alternative drugs included on the plan’s formulary, the lower cost-sharing drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering or utilization restriction exception.

When you request a formulary, tiering or utilization restriction exception you should submit a statement from your prescriber or physician supporting your request.

Generally, we must make our decision within 72 hours of getting your prescriber’s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber.

What do I do before I can talk to my doctor about changing my drugs or requesting an exception?

As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.  For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

If you are a resident of a long-term care facility, we will allow you to refill your prescription until we have provided you with up to a 91-day transition supply, consistent with dispensing increment, (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan.

If you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception.  Members who have a change in level of care (setting) will be allowed up to a one-time 30-day transition supply per drug. For example, members who:

  • Enter long-term care (LTC) facilities from hospitals are sometimes accompanied by a discharge list of medications from the hospital formulary, with very short term planning taken into account (often under 8 hours).
  • Are discharged from a hospital to a home.
  • End their skilled nursing facility Medicare Part A stay (where payments include all pharmacy charges) and who need to revert to their Part D plan formulary.
  • End a long-term care facility stay and return to the community.
  • If a member has more than one change in level of care in a month, the pharmacy will have to call us to request an extension of the transition policy.