Express Scripts Provider FAQs

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

New PBM

A. UHA is now switching to Express Scripts on June 1, 2016 in response to our customer feedback and our desire to reign in the skyrocketing costs of prescription drugs. In order for UHA to continue to care for the needs of our members, we have to align ourselves with partners who will be able to help us curb costs. Because of its size and position in the industry, Express Scripts offers more competitive pricing and service for our members.

A. Some medications, such as injectables, infusions, and some specialty drugs are part of a member's medical benefit rather than the pharmacy benefit. Express Scripts not only manages our pharmacy benefits for our members (PBM), but through their company Care Continuum, they can also manage medications under the member's medical benefits (MBM). There will be a MBM v. PBM Drug Lookup tool available on the Provider page of the UHA website at uhahealth.com/express-scripts.

Claims

A. Pharmacists can call the Pharmacy Help desk at (800) 922-1557 to assist with claims processing for medications managed under the member's pharmacy benefit (PBM) at any time of the day or night.

For help with claims processed according to the member's medical benefit (MBM), pharmacists can call UHA Customer Services, Monday – Friday, 8am to 4pm Hawaii Standard Time, at (808) 532-4000, Toll free: (800) 458-4600.

Formulary

A. Effective June 1, 2016 some medications will no longer be covered by the plan. Patient's taking these drugs will be given a 90-day grace period to continue to fill their prescriptions while they discuss alternative medications with their physicians. These members may have a higher copay for these excluded medications during this grace period. A letter will be sent to affected members notifying them about this change. Please see the list of excluded medications and their alternatives: uhahealth.com/express-scripts.

Prior Authorizations

A. UHA and Express Scripts will be sending members a letter, if their prescriptions will be affected by new prior authorization (PA) requirements, if they are no longer covered, or if they become non-preferred and will incur a higher copay. Members will be given a 90-day grace period to submit PA requests, or select alternative medications, if their drugs are no longer covered or now require a PA.

We recommend that you visit uhahealth.com/express-scripts to see if there will be changes to the coverage of your patient's medications:

  • Which medications are included in our Formulary and which medications will require PA, step therapy, or have a quantity limit
  • Which medications will not be covered

A. For fastest service visit Express Scripts' provider portal at express-path.com.

  • This one-stop site will allow you to submit PA requests for medications managed under the member's pharmacy benefit (PBM) and those managed under the medical benefit (MBM). In most cases you will be able to receive a real-time response. You can also set up email notifications which will send updates either on a daily basis, or if you prefer, only when a decision has been made.
  • PA requests for medications that are managed under the member's pharmacy benefit may also be submitted via covermymeds at covermymeds.com/epa/express-scripts.
  • Physicians may also call in PA requests for medications managed under the member's pharmacy benefit (PBM) at any time of the day or night. And in most cases, you will get a real-time response.
    PBM Phone: (800) 753 - 2851
    PBM Fax*: (877) 329-3760
  • For PA requests for medications managed under the member's medical benefit, call Care Continuum, the plan's Medical Benefit Manager (MBM), Monday – Friday, 8am to 7pm Eastern Standard Time. Messages received after business hours will be returned the next business day.
    MBM Phone: (866) 877-7042 (Press Option #1 for PA questions)
    MBM Fax*: (866) 877-7179

*Fax lines for both the PBM and MBM will accept any fax forms: Restat, Optum, UHA, or ESI.

A. Pharmacists may call MBM or PBM phone number to obtain status on PA's or check with the provider's office who submitted the PA. The Pharmacy can register at ExpressPAth also and submit PA. They can receive email notifications of status on a daily basis, or just when the decision has been made. Once ESI approves a PA, they will fax a notification to both the prescribing physician and the pharmacy listed on the PA.

  • PBM Phone: (800) 753–2851
  • MBM Phone: (866) 877-7042

A.  Many injectable, infusion and specialty medications are managed under the member's medical benefit (MBM) rather that the pharmacy benefit (PBM). Submitting PA requests via ExpressPAth eliminates the need to differentiate between the two. PA request for drugs managed as a medical benefit or as a pharmacy benefit may both be submitted on the same user friendly website express-path.com.

If you choose a different submission method, you can find out which medications are managed by the member's medical benefit (MBM), and which are managed by the member's pharmacy benefit (PBM) by using the MBM v. PBM Drug Lookup tool available on the Provider page of the UHA website at uhahealth.com/express-scripts.

A. Effective June 1, 2016 some medications will require PA that did not prior to June 1, 2016. If your patient is taking one of these drugs, they will be grandfathered for 90 days to allow time for a PA to be submitted. Affected members will receive a letter informing them of this change. Please see the list PA changes for June 1,2016: uhahealth.com/express-scripts.

A. These clinical programs protect your patient's health and save them money: step therapy (ST), drug quantity management (QL) and prior authorization (PA):

Step Therapy

  • Step therapy is a program for patients who take prescription medicine regularly to treat a long-term condition, such as arthritis, asthma or high blood pressure. It lets patients get the treatment they need affordably. It helps the plan sponsor maintain prescription-drug coverage for everyone the plan covers.
  • In step therapy, medicines are grouped in categories based on treatment and cost.
  • First-line medicines are the first step. First-line medicines are generic and lower-cost brand-name medicines approved by the U.S. Food & Drug Administration (FDA). They are proven to be safe, effective and affordable. Step therapy suggests that patients should try these medicines first because in most cases they provide the same health benefit as more expensive drugs, but at a lower cost.
  • Second-line drugs are the second and third steps. Second-line drugs typically are brand-name drugs. They are best suited for the few patients who don't respond to first-line medicines. Second-line drugs are the most expensive options.
  • Members who are currently taking a second line drug will not be asked to switch to a first line drug. They will be grandfathered indefinitely.
  • If you prescribe a new medication for a patient with a step therapy requirement, they will be asked to try a first-line medication before a Second-line medication.

Drug Quantity Management

  • The drug quantity management program makes sure that patients are getting the right amount of medication and that is prescribed in the least wasteful way. For example, you instruct your patient to take two 20mg pills each morning. If that medication was also available in 40mg pills, we would reach out to you about prescribing one 40mg pill a day instead of two 20mg pills. In addition, if you wrote the original prescription for 30 pills (a 15-day supply), the new prescription for 30 pills would last a full month — and the patient would have just one copayment, not two.
  • This program also makes sure that the prescription doesn't exceed the amount of medication that the plan covers. If the prescription is for too large a quantity, the pharmacist can fill the prescription for the amount that the plan covers or contact the you to discuss other options, such as increasing to a higher strength or a getting a prior authorization for the quantity originally prescribed.

Prior Authorization

  • When a prescription requires prior authorization, you can submit a PA request to Express Scripts or prescribe a different medication that is covered by the plan.

A. Registration is quick and easy! Visit provider.express-path.com.

You can register with only 6 simple steps and log in right away to begin submitting PA's online. A tutorial can be found here: provider.express-path.com/Tutorial.aspx.

A. With electronic prior authorization, spend more time with patients and less time faxing. Visit express-path.com to submit PA requests any time day or night and in most cases receive a response right away.

Previous versions of fax forms will continue to be accepted, but these forms will be removed from our website effective June 1, 2016.

  • Medications Managed as a pharmacy benefit can be faxed to: (877) 251-5896
  • Medications Managed as a medical benefit can be faxed to: (866) 877-7179

A. OptumRx will route any fax forms they receive after June 1, 2016 directly to Express Scripts.

A. Using the online PA portal, ExpressPAth, or submitting your PA via phone, is the fastest way to receive a response. In most cases you will receive a real-time answer, and if approved, the patient will be able to pick up their medications right away.

Appeals

A.  If you disagree with a decision reviewed under the member's pharmacy benefit (PBM), you may contact UHA's Health Care Service Department Monday-Friday from 8am to 4pm HST to request a peer- to-peer conversation within 30 days of the denial. We will arrange a time to for you to speak with our Medical Director or Chief Medical Officer to discuss reconsideration. If you would like to submit a formal, written appeal to UHA, please follow our appeals process described here: uhahealth.com/uploads/forms/guideline_initiate_appeal.pdf

If you disagree with a decision made by CareContinuum (MBM), please contact them at (866) 877-7042, Monday-Friday: 8am-7pm EST. With CareContinuum you will be able to request a peer to peer or submit a formal written appeal.

Contact Information

A. Express Scripts can answer your questions quickly and accurately around the clock for questions about drugs managed under the member's pharmacy benefit (PBM). For medications managed under the member's medical benefit (MBM), any calls received outside of business hours will be returned the next business day.

UHA's phone lines are also available from 8am to 4pm, Monday through Friday, except for major holidays. A representative can be reached at: 808-532-4000 (or 800-458-4600 from the neighbor islands) at the following extensions:

  • Customer Services: ext. 297
  • Health Care Services: ext. 300
  • Employer Services: ext. 299
  • Premium Billing: ext. 353
Express Scripts Contact Information
MBM/PBM Purpose Phone/Fax Hours
PBM Member Customer Service: Specific number for member inquiries; listed on the back of the member ID cards. Phone:
(855) 891-7978
Available 24/7
Prior Authorizations: Contact for physicians to call or fax in PHARMACY prior authorizations. Phone:
(800) 753 - 2851
Fax:
(877) 329-3760
Pharmacy Help Desk: For pharmacy use only to assist with getting a claim to adjudicate or understanding a reject message. Phone:
(800) 922-1557
TDD: Member Customer Service number for hearing impaired members. Phone:
(800) 759-1089
MBM Prior Authorizations: Contact for physicians to call or fax in MEDICAL drug prior authorizations. Phone:
(866) 877-7042
Fax:
(866) 877-7179
Mon - Fri
8AM - 5PM (EST)
2AM - 1PM (HST)