Is My Medication Covered?

If your drug is not included in the formulary (list of covered drugs), you should call Member Services at
1-844-282-3025, 5 days a week, 8 a.m. to 5 p.m. local time. Members can all dial 711 for TTY.

You can double-check if the drug is covered, and if it’s not, you have two options:

• Ask Member Services for a list of similar drugs that are covered by CHRISTUS Health Plan. When you receive the list, share it with your doctor and ask him or her to prescribe a similar drug that is covered.
• Ask CHRISTUS Health Plan to make an exception and cover your drug (see the next question for more details).

You can ask CHRISTUS Health Plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make.

• You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined cost-sharing level, and you would not be able to ask us to provide the drug at a lower cost-sharing level.
• You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, CHRISTUS Health Plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount.

Generally, CHRISTUS Health Plan will only approve your request for an exception if the alternative drugs included on the plan’s formulary would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

For requests for benefits that do not involve exceptions, the Plan will provide notice of its decision within 24 hours after receiving an expedited request or 72 hours after receiving a standard request. For requests for benefits that involve exceptions, the adjudication timeframes do not begin until the member’s prescriber submits his or her supporting statement to the Plan for review.

For payment requests, including payment requests that involve exceptions, CHRISTUS Health Plan will provide written notice of its decision (and make payment when appropriate) within 14 calendar days after receiving a request. If CHRISTUS Health Plan coverage determination is unfavorable, the decision will contain the information needed to file a request for appeal/redetermination with the Plan.

As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription.

You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day supply, we will not pay for these drugs, even if you have been a member of the plan less than 90 days.

Once it has been identified that you need an exception for a drug that is not on the formulary, Member Services will help you with the next steps to request an exception. For more detailed information about your CHRISTUS Health Plan prescription drug coverage, please review your plan forms and documents .

Have another question you don’t see here? Contact us or call member services at 1-844-282-3025 and we’ll help you find what you need. For TTY services, please call 711.

 

Consumer Advisory Board 
Members of CHRISTUS Health Plan have the opportunity to share feedback with us! If you would like to be a part of the CHRISTUS Health Plan Member Advisory Board, please let us know. You can tell us you are interested by calling Member Services at 1-844-282-3025. For TTY services, please call 711.

 

To participate in the Member Advisory Board, you must be: 

• A current enrollee of a health plan offered in Texas or Louisiana; 
• An employee of a group that subscribes to the health plan; or 
• A representative of a consumer organization that represents the interests of health care consumers. No member of the health plan’s consumer advisory board shall be an employee of the health plan or its affiliates, or an immediate family member of a health plan employee. 

The Member Advisory Board meets quarterly and serves to advise the health plan about general operations from the member perspective. We will review the Member Advisory Board recommendations at the health plan Quality Improvement Committee. After review, the CHRISTUS Health Plan Chief Executive Officer will respond to the Member Advisory Board regarding the recommendations.

During a drug utilization review, we check your prescriptions and look for problems like:

• Possible medication errors
• Duplicate drugs that are unnecessary
• Drugs that are inappropriate because of your age or gender
• Possible harmful interactions between drugs you are taking
• Drug allergies or dosage errors

These reviews are especially important if you have multiple doctors who prescribe medications. We conduct reviews each time you fill a prescription and on a regular basis. If we see a problem during our review, we will work with your doctor to correct it.

Utilization management is a practice where some medical services and drugs are evaluated for need before they can be used. This means that for certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors and pharmacists developed these rules to help members use drugs effectively and keep coverage affordable. Examples of utilization management include:

• Prior Authorization: We may need you to get approval from us before you fill certain prescriptions. If you don’t get approval, we may not provide coverage for the drug.
• Quantity Limits: We may limit or only cover a certain amount of a drug per prescription or for a period of time.
• Step Therapy: In some cases, members may need to try one drug to treat their condition before we will provide coverage for another drug.
• Generic Substitution: When a generic version of a drug is available, our pharmacies will automatically give members that version unless your doctor has told us that you must take the brand name drug.

You can find out if your drug is subject to these additional requirements or limits by looking in our formulary. If your drug does have additional restrictions or limits, you can ask us to make an exception to our coverage rules. Learn more about requesting an exception in the FAQ section.