Information contained within this website does not guarantee payment.  Each situation is subject to eligibility, plan provisions, and medical necessity. Please refer to your plan documents or call Member Services, 888-711-1444, with specific questions.

Express Scripts is a national company we contract with to process your pharmacy claims and to issue your drug benefit ID cards. They are also the health plan’s exclusive provider of mail order pharmacy services.

A drug formulary is a list of drugs that can be used by practitioners to identify drugs that offer the greatest overall value. A committee of physicians, nurse practitioners, and pharmacists maintains the formulary.

There are many reasons a prescription will not process at the pharmacy. The following is a list of common reasons. For your specific situation, please contact Member Services at (920) 490-6900 or toll-free at 1-888-711-1444.

• A limited number of formulary drugs must meet specific criteria for use before they will be considered a covered benefit. Your practitioner may be required to send us certain medical information to help us make that decision. The practitioner’s office is notified as to whether or not the drug is approved.
  
  If a drug pre-authorization request has not been submitted, or the authorization has been denied, your pharmacy will not be able to file the drug claim under your prescription benefit – and you will be responsible for the entire cost of the prescription.
• The pharmacy may be submitting the claim under the wrong family member. For example, a prescription for an oral contraceptive will only process if the family member is female.
  
• Some drugs are not taken every day (e.g. migraine medications). Therefore, the amount you can get per copay is limited to what would be typically needed for that condition. If the pharmacy is submitting a quantity larger than what is allowed, the prescription will not process.
  
• Retail pharmacies are only able to dispense up to a continuous 30-day supply of medication. If your pharmacy is trying to dispense greater than this amount, the prescription will not process.

Brian Gruselle.pdf

Approximately 50,000 pharmacies across the country accept your Express Scripts Drug Card - including all major chain pharmacies (Walgreens, Wal-Mart, CVS, Osco, Eckerd, Albertsons, Rite-Aid). If you need a prescription, just present your Express ID card along with your prescription at a participating pharmacy provider. For covered drugs, you will only be responsible for your copay.

However, if you are in an area where no plan pharmacy is within a reasonable distance, and your prescription needs are urgent (e.g. an antibiotic for an infection, pain medication for a broken bone), you will need to pay for the entire cost of the prescription. You may then submit a manual drug claim reimbursement form (click on the link that follows this paragraph).  It will typically take 4-6 weeks for manual claims to be processed.

Express Scripts Claim Form 2007.pdf

FDA-approved drugs that, by law, require a prescription from a licensed practitioner (e.g. physician, nurse practitioner) are covered under your prescription drug benefit. These are also known as “legend” drugs because they all contain the legend “Caution: Federal Law Prohibits Dispensing Without a Prescription” or “Rx Only” on their label.

The only exceptions are insulin and disposable diabetic supplies – which, by law, do not require a prescription. However, to be eligible for coverage, the health plan requires that they must be medically necessary and written on a prescription.

The following types of drugs are commonly excluded from most plans:

• Drugs to treat infertility.
• Compounded medications that do not contain at least one legend ingredient.
• Non-legend drugs (i.e. those available without a prescription).
• Investigational drugs.
• Drugs not obtained from a plan pharmacy.
• Replacement medications resulting from loss, theft, or damage.
• Any drug used for weight control.
• Drugs used for cosmetic purposes.
• Drugs to treat nail fungus.

The following are in place to ensure your prescription drug claims are processed correctly with regard to your benefit:

• Quantity Level Limits – some drugs are not taken every day (e.g., migraine medications). Therefore, the amount you can get per copay is limited to what would be typically needed for that condition.
  
• Generic Substitution – when an FDA-approved generic is available, the health plan may limit coverage to the generic form of a drug. If the member requests the brand, he/she will be responsible for the appropriate brand copay plus the difference in cost between the brand and the generic.
  
• Pre-Authorization – a limited number of drugs must meet specific criteria for use before they will be considered a covered benefit. Your practitioner may be required to send us certain medical information to help us make that decision. The practitioner’s office and member are notified as to whether or not the drug is approved.
  
  If a drug pre-authorization request has not been submitted, or the authorization has been denied, your pharmacy will not be able to file the drug claim under your prescription benefit – and you will be responsible for the entire cost of the prescription.

If a member would like to initiate the pre-authorization process with their provider, he/she may print the form below (click on the link that follows this paragraph) and give it to the provider.

PriAuthForm.pdf

Insulin syringes, alcohol swabs, lancets, lancet devices, blood glucose test strips, urine glucose test strips, ketone test strips, glucose/ketone combination strips, and insulin “pen” injection devices.

Most plans allow you to receive up to a 30 consecutive days supply from a retail pharmacy that participates in the plan. For those who have mail order benefits through Express Scripts Mail Order Pharmacy, up to 90 consecutive days supply can be obtained. You can obtain your next refill when 75% of the days' supply is used. For example, if you get 30 days supply of your drug on June 1 from a local retail pharmacy, you can get your refill on June 23. If you received a 90 days' supply from the mail order pharmacy on June 1, you can order your refill on August 7.

If you obtained your original prescription from a national chain pharmacy (eg. Wal-Mart, Walgreens, Osco), you can refill your prescription at any one of their stores nationwide. If you do not use a national chain or one is not available in the temporary location, you may wish to obtain your chronic medications from the Express Scripts Mail Order Pharmacy through which you can get up to 90 consecutive days' supply. Finally, if neither of these options is feasible, you may contact Member Services toll-free at (888)-711-1444 to consider other alternatives.

When an FDA-approved generic to a brand name drug is available, the health plan may limit coverage to the generic form of a drug. The active ingredient(s) in a generic drug are chemically identical to their brand name counterparts. Pharmacists will dispense the generic medication in this situation. If the member requests the brand, he/she will be responsible for the appropriate brand copay plus the difference in cost between the brand and the generic.

Yes, You must choose a Primary Care Practitioner (PCP) at the time of enrollment.   You should establish a relationship with your PCP soon after the PCP selection is made. You can change your PCP at any time by calling the Member Service number 920-490-6900 local, or 888-711-1444 toll free.  This number is also on your medical ID card or found on this website under Contact Us.

You may seek care from a participating specialist without a Pre-Service Authorization.

If services are needed from a specialist that is NOT in our plan, your PCP must complete a Pre-Authorization requesting services from that non-participating specialist. This request to a non-participating specialist will be reviewed and approved or denied, by the plan's medical director or authorized designee. The patient should not make the appointment until the request has been reviewed. Notification of the decision will be sent to you, your PCP, and the referred specialist.

When specialty care need arises, you should seek care at a participating specialist whenever possible. If services from a non-participating specialist are necessary, the Pre-Service Authorization requirements for non-participating specialists will apply.  Additional costs such as usual and customary fee levels apply to non participating providers, usual and customary fees do not apply to participating providers.

Pre-Service Authorization is required for all non-participating providers and tertiary care specialists.  An authorization request form must be submitted by the covered person's Primary Care Practitioner (PCP) or a participating specialist.  After the review, a written response by Arise Health Plan will be sent to the covered person and/or his/her PCP. It is the covered person's responsibility to follow all authorization requirements.

Other types of services require a Pre-Service Authorization to determine if the services are experimental, investigative, medically necessary, or excluded. This type of of authorization is a request for a determination of benefits by Arise Health Plan, PRIOR to services being rendered. This request can be initiated by calling Arise Health Plan toll-free at (888)-711-1444 or (920) 490-6900. Benefit determination is based upon the information available to us at the time the request is received. 

Pre-Service Authorization IS required for:

• Inpatient stay in a skilled nursing facililty, hospital, or birthing center
• Transplants
• Home health care
• Hospice care
• Durable medical equipment over $500 or any durable medical equipment rentals
• Home infusion
• Prosthetics over $1,000
• New medical or biomedical technology
• New surgical methods or techniques

Pre-Service Authorization is NOT required for:

• Services performed by a participating provider, unless noted above
• Emergency care or urgent care at an emergency or urgent care facility
• Covered radiologist, pathologist, and anesthesiologist services at a participating facility

A Pre-Service Authorization must be obtained prior to the patient being seen by a specialist outside of the network, and before being seen at all inpatient facilities. The authorization must be approved by the medical director or his/her designated agent prior to the date(s) of service requested.

Pre-Service Authorization IS required for:

• Inpatient stay in a skilled nursing facililty, hospital, or birthing center
• Transplants
• Home health care
• Hospice care
• Durable medical equipment over $500 or any durable medical equipment rentals
• Home infusion
• Prosthetics over $1,000
• New medical or biomedical technology
• New surgical methods or techniques