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About Your Prescription Drug Coverage

About Your Prescription Drug Coverage

Whether you have a one-time illness or a chronic condition, RMHP knows the proper treatment and medication is of the highest importance. Read on to learn more about what we offer with our prescription coverage.  If you still have questions, we're happy to help.


 

Retail and Home Delivery Pharmacies

We know our Members need access to their prescriptions in a timely fashion, so RMHP offers a pharmacy network of more than 750 pharmacies that includes retail and an OptumRX home delivery pharmacy available to all Members. Prescriptions up to a 90 day supply may be ordered from most local retail pharmacies and from OptumRx home delivery.

Retail Pharmacies

Retail pharmacies are ideal for one-time prescriptions or those prescriptions needed immediately. Most retail pharmacies will fill your maintenance prescription for a 90 day supply at your request, and you may receive a copay discount. This discount will be the same whether you use a retail pharmacy or OptumRx home delivery pharmacy. Please check your plan documents for details. Some exclusions apply. Use our online Pharmacy Directory to find a local pharmacy close to your home or work, or contact our friendly Customer Service team.

Find a pharmacy

RMHP DualCare: Find a Pharmacy

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Contact us

Home Delivery Pharmacies

Home Delivery pharmacies offer convenient home delivery of medications that you use on a regular basis.  RMHP is proud to partner with OptumRx home delivery services.

Already Enrolled?

You can order a refill for a prescription with OptumRx Home Delivery Pharmacy by accessing the OptumRx portal.

Access OptumRx

Not Yet Enrolled? Sign up for OptumRx Home Delivery

You can place a home delivery order with OptumRx by taking any of these actions:

  • Access the OptumRx portal.  You can also access the OptumRx portal by logging into MyRMHP.
  • Access OptumRx
  • Have your doctor send an electronic prescription to OptumRx.
  • Call OptumRx home delivery.
  • Download and complete the New Prescription Mail-In Order Form
  • Download the form

Specialty Pharmacies

Specialty prescription medications are usually high-cost medications that need special handling. We’re proud to partner with BriovaRx® as our preferred specialty pharmacy. With BriovaRx, you’ll have access to experienced pharmacists and nurses who can provide information about why your medication was prescribed, how it works, and how to administer and store it. Your medication will be shipped wherever you need it — in safe, temperature-controlled, and tested packaging.

If you have specialty medications you would like to fill through BriovaRx, you can:

Access BriovaRx

We're Here to Help

If you have questions, just ask.  We can help you learn more about:

  • Your prescription
  • Prescription costs
  • Drug interactions
  • Side effects
  • The availability of generic substitutes

We can also help you with a medication review. Our pharmacists are also available to review your current medications and identify potential drug interactions or more cost-effective alternatives. To learn more, please contact us at 970-255-5677 or toll free 877-288-5773, or email us at RxMedReview@rmhp.org.

Drug Formularies

  • Copayment tiers
  • Quantity limits for medications (if applicable)
  • Prior authorization requirements for medications (if applicable)
  • Drugs that are not covered
  • Drugs that may be subject to special Affordable Care Act coverage

View our drug formularies

Download formulary changes for the Good Health formulary

Download formulary changes for the RMHP Prime and CHP+ formulary

Prior Authorization

Certain drugs must be prior authorized by the Pharmacy Department. To request prior authorization, please complete and submit the below form. You may also contact a representative at 970-248-5031 or 800-641-8921. When all required information is received by us, you will be notified of the authorization decision within 48 hours.

Submit an elctronic prior authorization request

Download Good Health prior authorization drug list

Download Good Health drugs requiring step therapy

Download Medicare Part D prior authorization form

Download RMHP Prime and CHP+ prior authorization drug list

Download RMHP Prime and CHP+ drugs requiring step therapy

Download RMHP Advantage Four-Tier prior authorization drug list

Download RMHP Advantage Four-Tier drugs requiring step therapy

View printable RMHP Prime and CHP+ prior auth drugs

View printable Good Health prior auth drugs

View printable RMHP Advantage Four-Tier prior auth drugs

View printable Medicare Cost Part B prior auth drugs

View printable D-SNP Part B prior auth drugs

Submit an electronic formulary exception request

Download brand name drug request form

Step Therapy and Prior Authorization Drugs for RMHP DualCare Plus

A list of step therapy drugs for RMHP DualCare Plus Members can be found using the drug search tool through OptumRx. Step therapy drugs may be effective, lower-cost drugs that treat the same medical condition as a drug you currently use. You may be required to try one or more of these other drugs before the plan will cover your drug. You can also view the list of drugs requiring prior authorization using this tool. Visit the link below, then select the PA/ST tab to download and view these lists..

View step therapy and prior authorization drug lists

Please note: By selecting this link, you will be leaving rmhp.org.

Eligible Over-the-Counter and Prescription Drug Reimbursement

If you paid in full for an Over-the-Counter or prescription medication that is eligible for reimbursement, complete and submit the Prescription Drug Reimbursement Form:

Download Prescription Reimbursement Form

Machine readable JSON files

Drugs File

Providers File

 

Quality assurance policies and procedures

The Utilization Management/Quality Assurance (UM/QA) program helps ensure safe and appropriate use of prescription drugs covered under Medicare Part D. Rocky Mountain Health Plans (RMHP) offers the UM/QA program at no additional cost to its members and their providers.

This program focuses on:

  • reducing adverse drug events and drug interactions
  • optimizing medication utilization and
  • providing incentives to reduce costs when medically appropriate.

Utilization Management

The UM/QA program has utilization management tools to encourage appropriate and cost-effective use of Medicare Part D prescription drugs. These tools include, but are not limited to: prior authorization, clinical edits, quantity limits, and step therapy.

Quality Assurance

As part of the UM/QA program, all prescriptions are screened by drug utilization review systems to detect and address the following clinical issues:

  • Morphine Milligram Equivalent (MME) limits
  • Opioid day supply limits (7-day supply)
  • Therapeutic dose limits
  • Clinically significant drug-drug and drug-disease interactions
  • Therapeutic duplication
  • Inappropriate dosage or duration of therapy
  • Patient-specific drug contraindications (e.g., based on gender or age)
  • Under-utilization

The UM/QA program helps ensure that a review of prescribed therapy is performed before each prescription is dispensed. These concurrent drug reviews are implemented as clinical edits at the point-of-sale or point-of-distribution.

In addition, retrospective drug utilization reviews identify inappropriate or medically unnecessary care. We perform ongoing, periodic review of claims data to evaluate prescribing patterns and drug utilization that may suggest potentially inappropriate use.


Declaration of Disaster or Emergency

If you are affected by a disaster or emergency declaration by the President or a Governor, or an announcement of a public health emergency by the Secretary of Health and Human Services, there is certain additional support available to you.

  • Medicare-covered plan benefits may be provided at specified non-contracted facilities (note that Part A and Part B benefits must be obtained at Medicare certified facilities);
  • Cost- sharing for out-of-network services approved by RMHP will be reduced to in-network cost-sharing amounts; and
  • The 30-day notification of changes requirement to members is waived, as long as all the changes (such as reduction of cost-sharing and waiving authorization) benefit the member.

If CMS hasn’t provided an end date for the disaster or emergency, plans will resume normal operation 30 days after the initial declaration.

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