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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

RMHP offers a large pharmacy network, and we have OptumRX home delivery pharmacy available to all Members. .

Retail Pharmacies

Retail pharmacies are ideal for one-time prescriptions or those prescriptions needed immediately. Some exclusions apply. Use our online Pharmacy Directory to find a local pharmacy close to home, or contact our friendly Customer Service team.

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Individual & Family Plans: Find a pharmacy

Medicare / DualCare: Find a Pharmacy

Medicaid and CHP+: Find a Pharmacy

Contact us

Home Delivery Pharmacies

Home Delivery pharmacies offer convenient home delivery for medications that you use on a regular basis typically for a 90 supply. RMHP is proud to partner with OptumRx Home Delivery. Some exclusions apply.

Already Enrolled in Home Delivery?

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 Optum Specialty Pharmacy as our preferred provider. With Optum Specialty Pharmacy, 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 Optum Specialty Pharmacy, you can:

We're Here to Help

For more information about the following, visit OptumRx. If you have questions, just call us at 970-243-7050800-346-4643 (TTY: 711)

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

We can also help you with a medication review. Our pharmacists are 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

RMHP Drug Formularies provide helpful information about your prescription drug coverage, including:

  • 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

Prior Authorization

Certain drugs must be prior authorized. To request prior authorization, please see the resources below. You may also contact a representative at 970-248-5031 or 800-641-8921.

Requesting a Pharmacy or Formulary prior authorization

Select from the resources below to request authorization for a drug obtained through a pharmacy. Drugs on formularies are typically self-administered and provided by an in-network retail or mail order pharmacy.

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Submit a pharmacy drug prior authorization request online

View printable Medicaid and CHP+ pharmacy drug criteria

View printable Individual and Family Plan pharmacy drug criteria

Download Medicare Part D request form

Requesting a Medical or Physician administered drug

Medical or out-patient drugs are those that are administered by a physician. These drugs do not originate from a pharmacy, since they are provided by the physician and are not self-administered. Some medical drugs require prior authorization. Select from the resources below to request authorization for a medical drug.

Submit a request for an Individual and Family Plan Medical Drug online

Submit a Coverage Exception Request for a Medical Drug

View printable RMHP Prime and CHP+ prior auth drugs

View printable Individual and Family Plan Medical prior auth drugs

View printable Medicare Part B medical prior auth drugs

Step Therapy and Prior Authorization drugs for RMHP DualCare Plus and Medicare Advantage

A list of step therapy drugs for RMHP Dual Special Needs Plan (DualCare Plus) or Medicare Advantage (CareAdvantage) members can be found using the drug search tool. 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 for your plan, below, then select the PA/ST tab to download and view these lists.

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DualCare Plus step therapy and prior authorization drug lists

CareAdvantage step therapy and prior authorization drug lists

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

 

Medicare Part D - 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.

Pharmacy Library

Use these resources to learn more about medication costs and generic drugs.

Let's Find You Great Health Insurance

Since 1977, Colorado retirees like you have trusted RMHP to get the most out of their Medicare benefits. Enjoy easy enrollment, flexible options, and a large provider network when you choose RMHP. Let us help you enjoy your retirement.

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