Express Scripts Member FAQs

This information is subject to change. You can get more information and updates to the contents of this FAQ at express-scripts.com.

A. With Express Scripts you have access to pharmacists who have expertise in the medications for high blood pressure, asthma, diabetes or cancer. Pharmacists at Express Scripts can help with questions about your medications. The pharmacists can also advise you how to potentially reduce your medication costs.

When you log into your Member Portal at UHA, either on the website or the mobile site, you can also access your current prescription information with Express Scripts. You may also log in directly to Express Scripts at express-scripts.com or by calling the number listed below.

  • Customers calling about their prescriptions: 855-891-7978
  • Pharmacists (for Rx or PA information): 800-922-1557
  • Providers (for PA): Express PAth

Your doctor can call in a prescription over the phone or enter the information on the website. In most cases, your doctor will get a real-time response.

A. It is best to contact Express Scripts directly with questions about your copay or out of pocket costs. UHA’s phone lines are also available 8 am to 4 pm, Monday - Friday, except for major holidays. A representative can be reached at 808-532-4000 (or 800-458-4600 from the neighbor islands) at the extensions below:

  • Customer Services: ext. 297
  • Health Care Services: ext. 300
  • Employer Services: ext. 299
  • Premium Billing: ext. 353

ID Card

A. Should you misplace or not receive a new card, you may submit a request via our website or call our Customer Services department at 808-532-4000 or 1-800-458-4600 (from the neighbor islands). Your card will have the following information that your pharmacy needs to process your prescription(s):

  • RxBin: 003858
  • RxPCN: A4
  • RxGroup: NKTA

Please note that your drug plan may be self-insured by your employer or you may not have a drug benefit.

A. Yes. This is very important in order to avoid delays in processing extended or autofill prescriptions, as the pharmacy may not update the information until the member receives a rejection. The key is to give your pharmacist these numbers:

  • RxBin: 003858
  • RxPCN: A4
  • RxGroup: NKTA

These are the same for everyone with UHA drug coverage.

Reimbursement

A. You may submit your receipts by fax directly to Express Scripts at 877-329-3760. There is a direct member reimbursement form (DMR) located on the Express Scripts website that you may send with your receipts that will ensure timely reimbursement.

A. Non-participating pharmacies may require you to pay for your prescription in full and have you file your claim with UHA. You can submit your receipts for reimbursement via fax to Express Scripts at 877-329-3760. There is a direct member reimbursement form (DMR) located on the Express Scripts website that you may send with your receipts that will ensure timely reimbursement. You should note that the reimbursement is likely to be less than if you used a participating pharmacy.

Home Delivery

A. You can still use Pharmacare for your mail order or specialty drugs. You may also use Express Scripts PharmacySM for:

  • Home Delivery
  • Extended Fill
  • Mail Order
  • Specialty Drugs (via Accredo)

Benefits and Coverage

A. You can either get vaccinations at your doctor's office or at a pharmacy in network.

A. If a pharmacist tells you that your prescription needs a PA, we need to contact your doctor to be sure that the drug is right for you. We also need to check if your plan covers the drug. This is similar to when your healthcare plan authorizes a medical procedure in advance.

When a prescription requires a PA, your doctor can call Express Scripts or prescribe a different drug that is covered by the plan. Only doctors can give Express Scripts the information they need to see if the drug is covered. Express Scripts answers PA phone lines 24 hours a day, seven days a week. A decision can be made right away. If the drug is covered, you will pay your normal copayment. If you choose the medication that is not covered, you will pay the full price.

A. Your doctor can use ExpressPAth online, or submit a PA by phone. In most cases your doctor will receive a real-time answer. If approved, you will be able to pick up your medication right away.

A. If you disagree with a decision made by Express Scripts, your doctor may contact UHA's Health Care Service department Monday-Friday, 8am to 4pm HST to request a peer to peer within 30 days of the denial. We will arrange a time for your doctor to speak with our Medical Director or Chief Medical Officer. If you or your doctor would like to submit a written appeal, please follow our appeals process at: uhahealth.com/uploads/forms/guideline_initiate_appeal.pdf

Some drugs are managed under your medical benefits rather than by your pharmacy benefits. Some injectable drugs are reviewed by CareContinuum, an Express Scripts company. If you disagree with a decision made by CareContinuum, please contact them at (866) 877-7042, Monday-Friday, 8am to 5pm EST. With CareContinuum, your doctor will be able to request a peer to peer or submit a written appeal.

A. COB (coordination of benefits) claims may be subject to PA, which means if the drug or procedure needs a PA from UHA, even if UHA is the secondary insurer, the PA will still need to be submitted.

Primary insurance coverage applies to the original claim, but the member is responsible for the remaining balance. That amount will come in on a claim to UHA as the secondary insurer. Some examples are listed below:

Note: Primary insurance already paid on the claim, so the COB claim comes to UHA as secondary insurance.

Example #1 $30 patient responsibility Example #2 $30 patient responsibility
  - $0 deductible   - $0 deductible
  - $45 UHA Drug Plan copay   - $15 Drug Plan copay
  UHA pays $0   UHA pays $15
  Member pays $30   Member pays $15
 
Example #3 $500 patient responsibility Example #4 $500 patient responsibility
  - $0 deductible   - $0 deductible
  - $15 Drug Plan copay   - $100 Drug Plan co-insurance (20% 4th tier)
  UHA pays $485   UHA pays $400
  Member pays $15   Member pays $100

Plans P, Q, & S have $150, $200, & $250 drug price limits respectively, which means the coinsurance will hit the "4th Tier 20% coinsurance requirement" if the drugs exceed those amounts.

Definitions

A.

  • Generic drugs are the lowest cost drugs; copies of patented Brand name drugs that have the same chemical action as Brand name drugs.
  • Brand medications are either Preferred or Non-Preferred (sometimes referred to as Formulary or Non-Formulary).
  • Preferred Brand drugs have a lower copay than Non-Preferred Brand drugs.
  • Non-Preferred Brand drugs are newer drugs that are usually the most expensive drugs available among them all.

A. Step therapy is for people who take prescription drugs daily to treat a long-term condition (arthritis, asthma or high blood pressure). It lets you get treatment at a lower cost. It also helps your employer maintain prescription-drug coverage for everyone your plan covers.

In step therapy, medicines are grouped in categories based on treatment and cost.

  • First-line medicines are the first step. They are generic and lower-cost brand-name drugs approved by the U.S. Food & Drug Administration (FDA). They are proven safe, effective and affordable. Step therapy suggests you try these drugs first. In most cases they provide the same health benefits as more expensive drugs, but at a lower cost.
  • Second-line drugs are the second and third steps. These are often brand-name drugs. They are best for patients who don't respond to first-line drugs. Second-line drugs are the most expensive.

Generic drugs have the same chemicals as the brand-name. They also have the same effect. Though generics may have a different name, color and/or shape, they have been through the same testing as the original drug. They have also been approved by the FDA as safe and effective in the same process as the original drug.

Unlike manufacturers of brand-name drugs, the companies that make generic drugs don't spend as much money on research and advertising. As a result, generic drugs cost less than the original brand-name drug and the savings get passed on to you.

The first time you try to fill a prescription that isn't for a first-line medicine, your pharmacist should explain that step therapy asks you to try a first-line medicine before a second-line drug. Only your doctor can change your current prescription to a first-line drug covered by your plan.

A. Quantity limits make sure that you get the right amount of medication and in the least wasteful way. For example, your doctor might have told you to take two 20mg pills each day. If that medication was also available in 40mg pills, our staff would ask the doctor to prescribe one 40mg pill a day instead of two 20mg pills. In addition, if the doctor wrote the original prescription for 30 pills (a 15-day supply), the new prescription for 30 pills would last a full month — resulting in just one copayment, not two.

If the prescription is for a larger quantity, the pharmacist can fill the prescription for the amount that the plan covers or contact the doctor to discuss other options. The pharmacist may increase the strength or get a PA for the quantity originally prescribed.