Health Insurance Exchange Pharmacy

Pharmacy: Health Insurance Exchange

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: 1-884-470-1531
Pharmacy Help Desk: 1-800-922-1557
Fax Number:1-877-329-3760

Coverage Determination (ESI)
Standard/Expedited Coverage Review: 1-800-935-6103

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.

For More Information

Please refer to the Provider Manual.