CHRISTUS Health Plan includes coverage for prescription drugs. Pharmacy
claims are processed by Express Scripts (ESI), the CHRISTUS Health Plan
pharmacy benefit management vendor. The formulary includes coverage of
generic drugs, as well as many brand-name drugs, non-preferred brands and
specialty drugs. Formularies are reviewed by a Pharmacy and Therapeutics
Committee composed of provider and pharmacists. Providers can view a copy
of the formulary on the CHRISTUS Health Plan website. Some of these drugs
have precertification or step-therapy requirements or quantity limits,
defined as:
-
Prior Authorization (PA): CHRISTUS Health Plan requires the provider to
get prior authorization before the drug will be approved for coverage,
-
Quantity Limits (QL): For certain drugs, CHRISTUS Health Plan limits
the amount of the drug it will cover for a given duration of time (i.e.
30 pills every 30 days).
-
Step Therapy (ST): In some cases, CHRISTUS Health Plan requires trial
and failure of certain drugs to treat a medical condition before it
will cover another drug for that condition.
The following contact numbers depict the pharmacy related services provided
by CHRISTUS Health Plan as well as the contact information:
Pharmacy Related Service
Prescription Drugs (ESI)
Pharmacy Department: 1-844-569-2830
Pharmacy Help Desk: 1-800-922-1557
Fax Number:1-877-329-3760
Coverage Determination (ESI)
Standard/Expedited Coverage Review:
1-800-935-6103
ePA Coverage Review:
Learn More
Formulary Exceptions (ESI)
Coverage Review: 1-800-935-6103
Prescription Drugs by Mail Order
Members can use the mail-order service to fill prescriptions for
maintenance drugs (i.e., drugs taken on a regular basis for a chronic or
long-term medical condition). For mail-order prescriptions, the provider
must write on the maintenance drug prescription whether it is for a 31-,
62- or 93-day supply. When mailing in a prescription to the mail-order
service for the first time, the member should allow up to two weeks for the
prescription to be filled. For refills of the same prescription, members
should allow up to 7-10 days for mailing and processing.
If a member runs out of a medication before receiving a new supply from the
mail-order pharmacy, please call 1-844-470-1531.
Coverage Determinations for Prescription Drug Benefits
A coverage determination is any decision CHRISTUS Health Plan makes
regarding:
-
A decision about whether to provide or pay for a drug, including a
decision not to pay because the drug is not on the Plan’s formulary,
the drug is determined not to be medically necessary, the drug is
furnished by an out-of-network pharmacy or we determine the drug is
otherwise excluded, but the member believes it may be covered by the
Plan
-
Failure to provide a coverage determination in a timely manner, when a
delay would adversely affect the member’s health
-
A decision concerning a formulary exception request
-
A decision on the amount of cost sharing for a drug
-
A decision on whether a member has satisfied a precertification or
other utilization management requirement
Two decisions govern the need for prescription drugs the member has not yet
received:
-
A standard decision made within the standard 72-hour time frame
-
An expedited decision made within 24 hours
An expedited decision can only be requested if the member or any provider
believes waiting for a standard decision could jeopardize the member’s
life, health or ability to regain maximum function. This is called the
expedited criteria. The member or a provider can request an expedited
decision. If a provider requests an expedited decision or supports a member
in asking for one and if the provider indicates the situation meets the
expedited criteria, CHRISTUS Health Plan will automatically provide an
expedited decision within 24 hours from the initial request.
Formulary Exceptions
If a prescription drug is not listed in the CHRISTUS Health Plan formulary,
please check the updated formulary on the
Express Scripts website. The website formulary is updated frequently with any changes.
If the drug is not on the formulary, there are two options:
-
The prescribing provider can prescribe another drug that is covered on
the formulary.
-
The patient or prescribing provider may ask CHRISTUS Health Plan to
make an exception (a type of coverage determination) to cover the
non-formulary drug. If the member pays out-of-pocket for a
non-formulary drug and requests an exception CHRISTUS Health Plan
approves, CHRISTUS Health Plan will reimburse the member. If the
exception is not approved, the member may appeal the Plan’s denial.
In some cases, CHRISTUS Health Plan will contact a member who is taking a
drug that is not on the formulary. CHRISTUS Health Plan will give the
member the names of covered drugs used to treat his or her condition and
encourage the member to ask his or her provider if any of those drugs would
be appropriate options for treatment. Also, members who recently joined
CHRISTUS Health Plan may be able to get a temporary supply of a drug they
are taking if the drug is not on the CHRISTUS Health Plan formulary.
Specialty Pharmacy Network
Please Note: Effective January 1, 2020, Accredo Specialty Pharmacy will be the preferred specialty pharmacy for CHRISTUS HP non-Medicare members. Express Scripts is currently informing impacted patients that they will no longer be able to obtain specialty medications at their current pharmacy. These patients will be asking for a new prescription or requesting that Accredo® contact you directly.
Accredo is a specialty pharmacy that serves patients with complex and chronic health conditions. Accredo’s has pharmacists and nurses who received specialized training in the diseases they treat and are available to provide personalized care to patients. Below are some of the services Accredo can offer CHRISTUS Health Plan members:
- 24/7 Support. Trained pharmacists and nurses are available around the clock to answer questions
- Supplies. Supplies, such as syringes, needles, and sharps containers, will be provided with medications
- Safe, fast delivery. Including those that require special handling, such as temperature-sensitive medications.
- Digital capabilities. Patients can use texting or the Accredo App to assist with communicating with Accredo
- Refill reminders.
- Drug safety monitoring. As an Express Scripts pharmacy, Accredo can access patient’s prescription information on file at all Express Scripts pharmacies to monitor for potential drug interactions and side effects
- Adherence checks. Through counseling, personal support, and regular contact, we encourage our patients to adhere to their treatment regimen for the best possible results.
- Home infusion services and nursing support.
Please choose one of the following options to submit a prescription for specialty medications on behalf of your patients:
OPTION 1 — Send new prescriptions to Accredo by e-prescribing; visit accredo.com for instructions.
OPTION 2 — Fax new prescriptions to Accredo at 1-800-391-9707.
OPTION 3 — Call Accredo at 1-866-759-1557 to provide new prescriptions.
If Accredo specialty pharmacy does not meet your needs, the following alternative pharmacies can also be used to obtain specialty medication:
1. CHRISTUS St. Vincent’s Pharmacy: (505) 913-5000
2. CHRISTUS St. Michael’s Healthcare Center Pharmacy: (903) 614-2200
3. CHRISTUS SE TX-Jasper Memorial Pharmacy: (409) 381-5504
4. Glenwood Pharmacy: (903)792-8296
5. H-E-B Pharmacies: (877) 432‑9355
6. Kelly Drug: (903) 569-3882