Pharmacy FAQs

Seaside Health Plan works with MedImpact to provide your pharmacy benefits. Please see below for answers to commonly asked questions regarding Pharmacy. If your question is not listed below, please contact MedImpact Customer Service at (844) 513-6001 or customerservice@medimpact.com for additional assistance.

GENERAL QUESTIONS

What is MedImpact?

MedImpact is one of the nation's leading pharmacy benefit managers, serving the needs of more than 32 million Americans. Our clients include Fortune 500 corporations as well as other employers, unions, managed care organizations, Blue Cross and Blue Shield plans, insurance carriers, third-party administrators, and local, state and federal employee programs. MedImpact manages more than 100 million prescriptions annually through its nationwide network of more than 64,000 participating pharmacies.

MedImpact links patients, pharmacists and physicians together, helping ensure the appropriate use of medication for each individual based upon their personal medication profile, pharmacy benefit coverage, and best clinical practices. MedImpact products, programs and services are designed to help control total health care costs, improve quality of care and increase member satisfaction.

How does a member contact MedImpact?

A member may contact MedImpact via Seaside Health’s dedicated telephone number: Customer Support: 844-513-6001

PHARMACY QUESTIONS

How do I find a participating pharmacy?

Once signed in, you can find a participating pharmacy by clicking on either the Pharmacy Locator link located in the menu bar and entering your criteria. Pharmacy Locator was designed to help you identify pharmacies that participate in the network that serves your pharmacy benefit plan. At a minimum, you will need to enter city and state or zip, and select the distance you are willing to travel to a participating pharmacy. Pharmacy Locator will display up to 20 participating pharmacies within the specified travel radius. Note that you will need to be a registered user to utilize Pharmacy Locator.

Where can I get my prescription filled for the lowest cost?

The pharmacies that participate in the network serving your pharmacy benefit plan have agreed, typically through contractual arrangements, to provide covered pharmacy-related products and services for a defined reimbursement formula. Therefore, for covered medications, your cost (or copayment amount) should be the same at all participating pharmacies.

Can I get my medication at a non-participating pharmacy?

In most instances, you will not need to visit a non-participating pharmacy. Although the network that serves your pharmacy benefit plan may not include all pharmacies, MedImpact contracts with more than 64,000 pharmacies nationwide, which ensures access to a convenient participating pharmacy. When you choose to purchase a covered medication at a non- participating pharmacy, you may be required to pay a higher copayment amount or 100% of the cost. Then, if your plan sponsor allows for direct member reimbursement, you may submit a claim to MedImpact. To find a participating pharmacy, click on the Pharmacy Locator link located in the menu bar and enter your criteria. Refer to the Help Desk section for a direct member reimbursement claim form.

How do I transfer a prescription from a non-participating pharmacy to a participating pharmacy?

There are three ways to transfer your prescription:

  1. Take your labeled medication container from your previous pharmacy to the participating pharmacy. Your new pharmacy will contact your old pharmacy to transfer your prescription.
  2. Call the participating pharmacy and ask them to call your old pharmacy for prescription transfer information.
  3. Ask your doctor to contact the participating pharmacy directly.

Can I fill my prescriptions at a retail pharmacy and through mail order at the same time?

If applicable, you can fill your prescriptions at a 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 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 mail order or a participating Choice90Rx pharmacy.

Refer to your pharmacy benefit materials as supplied by your plan sponsor to determine if you have a mail order or Choice90Rx option.

Who should I contact about pharmacy issues?

If you should encounter any issues at a participating pharmacy, please contact the customer contact center toll-free at 844- 513-6001 or securely email customer service at customerservice@medimpact.com to give a detailed explanation of the issue. A representative will make an effort to resolve the issue. Refer to the Help Desk section for further contact information.

PHARMACY BENEFIT QUESTIONS

What is my copayment?

Once signed in, you can determine how much a medication may cost you at the point of service by clicking on either the Benefit Highlights or PilotRx link located in the menu bar.

Benefit Highlights displays your current copayment amounts and, if applicable, your deductible and maximum out-of-pocket expenses.

PilotRx provides formulary and non-formulary, brand and generic information and price estimates by pharmacy. Note that you will need to be a registered user to view Benefit Highlights or PilotRx.

Are there any differences in my copayment amounts when using mail order or the 90-day at retail program called Choice90Rx?

If your plan sponsor has allowed for mail order or the 90-day at retail program called Choice90Rx and you take a medication on an ongoing basis, you may be able to save money when you obtain up to a 90 day supply of medication. To view your copayment amounts, click on Benefits Highlights on the menu bar.

Refer to your pharmacy benefit materials as supplied by your plan sponsor to determine if you have a mail order or Choice90Rx option.

How do I determine if a medication is covered by my pharmacy benefit?

Once signed in, you can determine if a medication is covered by your pharmacy benefit by clicking on the PilotRx link located in the menu bar and entering your criteria. PilotRx presents a list of medications, defines the formulary status of each of those medications and, by highlighting generic availability, assists you in determining if there are other alternatives within a specific drug class that may be available at a lower cost. PilotRx also provide you with a cost estimate for a selected medication. Note that you will need to be a registered user to utilize PilotRx.

Does my pharmacy benefit cover any medication prescribed by my physician?

Your pharmacy benefit may not cover all medications prescribed by your physician. Some medications may be excluded from coverage.

To determine if a medication is covered by your pharmacy benefit, click on the PilotRx link located in the menu bar and enter your criteria. PilotRx will indicate if a medication is not covered (NC) in the status column of the formulary table.

For more detailed information, refer to the pharmacy benefit materials as supplied by your plan sponsor or employer.

Should I provide my physician with a list of medications covered by my pharmacy benefit?

Next time you go to your physician, you should bring a list of medications covered by your pharmacy benefit to keep with your medical file. By doing so, 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, click on the PilotRx link located in the menu bar and enter your criteria. There is a print option on the of each search results page. Note that you will need to be a registered user to utilize PilotRx.

Are all my prescriptions checked for drug interactions?

At the pharmacy, your pharmacist has the responsibility to use his or her professional judgment to assess the potential of your prescription having a drug interaction with other drugs you are taking. If you utilize your pharmacy benefit card when you obtain a medication, information about each drug is also sent to the MedImpact claims system and reviewed for any potential drug interactions based on your personal medication profile before your claim is approved by our systems. If the claims system identifies a potential drug interaction, a notification will be sent electronically to the dispensing pharmacist for their review and consideration.

Can I use my pharmacy benefit card in another state?

If you are in another state on vacation or a business trip, and you need to fill a prescription, you may present your pharmacy benefit card at any participating pharmacy along with your prescription. The pharmacist will process the prescription through the claims system and request the applicable copayment amount. To find a participating pharmacy, click on the Pharmacy Locator link located in the menu bar and enter your criteria.

Do some drugs have restrictions?

In some cases, your plan sponsor or employer may manage coverage of certain medications regardless of formulary status by requiring certain restrictions. Restrictions may include, but not be limited to quantity limitations, age and gender specifications, prior authorization, or step therapy. Refer to the Glossary of Terms in Benefit Highlights or PilotRx for term descriptions. For more detailed information, refer to the pharmacy benefit materials as supplied by your plan sponsor or employer.

What is prior authorization and do I have prior authorization for my medication?

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 customer contact center toll-free at 888-807-8106 or securely email customer service at customerservice@medimpact.com.

What happens if my prior authorization or medical exception request is denied?

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 or employer.

What is a controlled substance?

The federal government has categorized a class of medication as having a higher than average potential for abuse or addiction. Such medications, known as controlled substances, are divided into categories based on their potential for abuse or addiction. These medications range from illegal street drugs (C1) to medications with decreasing potential for abuse (C2 through C5). Prescriptions containing narcotics or amphetamines are often classified as C2, since there is a relatively high potential for abuse or addiction.

How soon can I get a refill?

Your plan sponsor sets the number of days supply you must finish before you are able to get a refill. If your physician allowed for a prescription refill, you can order your next refill after the “order after” date at the bottom of your prescription label.

What does days supply mean?

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.

Can I access my pharmacy claims history?

Once signed in, you can access your pharmacy claims history by clicking on the PersonalHealthRx link located in the menu bar, enter the prescriptions report section, and select your criteria.

Within this area, PersonalHealthRx allows you to view and print your pharmacy claims history for a specified time period. A prescriptions report includes medication name, fill date, prescription number, quantity, days supply, copayment amount, plan paid amount, prescribing physician and dispensing pharmacy. Pharmacy claims history can be provided to your physician for drug utilization review or compliance monitoring. Note that you will need to be a registered user to utilize PersonalHealthRx.

Is there an easy way to print a summary of annual pharmacy expenses?

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

What is a specialty medication?

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.