A: Pharmacy Reimbursement Guidelines

Effective 1/1/2015:

If you as a Nevada Health CO-OP (NHC) member pays out-of-pocket for a prescription and requires reimbursement they have to be processed Catamaran Rx.

This is done to ensure that the benefits reimbursed are done according to guidelines set in place by NHC and that Step Therapy and Pre-Authorization rules are followed. For the best benefit you should follow the steps outlined below.

Within 7 days of filling and paying for prescription:

1. In the case that there is an issue with eligibility and/or it is after hours and the member pays for the medication in full:

• You should call NHC as soon as possible (during normal business hours) at
  702-823-2667 or toll-free 855-606-2667 and explain the issue.
• Catamaran Rx will update and either CO-OP Care Crew or Catamaran Rx can contact the pharmacy to re-run the prescription. Since it is within 7 days, the pharmacy will reimburse you directly.
• For example, if you paid $100 for a prescription that normally would have only had a $10 co-pay, the pharmacy will refund $90 to you.

After 7 days of filling and paying for prescription:

1. In the case that there is an issue with eligibility and/or it is after hours and you pay for the medication in full:

• Since 7 days has already lapsed since you picked up your medication, you must follow the step below:
• If you have failed to call within the first 7 days, you must attach prescription label to the MEMBER REIMBURSEMENT DRUG CLAIM FORM and mail it to Catamaran Rx at:

Catamaran Rx
P.O. Box 968022
Schaumburg, IL 60196-8021     
 

REMEMBER: it is for your benefit to call the Nevada Health CO-OP as soon as possible to correct any eligibility information so you can receive the reimbursement through the pharmacy.

• If there is any other reason that you paid out-of-pocket for your medication such as requirements in regards to Pre-Authorization or Step Therapy, you need to call Catamaran Rx’s Pharmacy Help Desk at (855) 897-0304.
• You should be made aware that if original claim required pre-authorization or was subject to Step Therapy then your doctor may be required to call Catamaran Rx and submit clinical information for approval. Retro authorization can be requested.

If for any reason that you do not receive a response or a refund within 3 weeks, you can reach out to Catamaran Rx’s Pharmacy Help Desk at (855) 897-0304.

Quantity Limit Program

Catamaran, your pharmacy benefit manager, are committed to maximizing the value of your prescription drug benefit and lowering prescription costs.  The Quantity Limit Program is a clinical program designed to help meet these goals.

A: A Quantity Limit Program supports the management of your prescription drug plan by confirming that prescribed quantities are consistent with clinical dosing guidelines and medical literature.  This program was established to provide safe and appropriate use of certain medications.

A: If you are currently receiving a quantity of medication below the identified quantity limit, your prescription will be covered under your pharmacy benefits.  If your doctor writes a prescription for an amount greater than the quantity limit, you will need to obtain a prior authorization from Catamaran before additional quantities are covered.  You, your pharmacist or your doctor can call Catamaran to initiate the prior authorization process.  Catamaran will then contact your doctor to get the information needed to determine coverage for your medication.

A: Some medications have a higher possibility of overuse or may be prescribed outside of clinical dosing guidelines.  In some cases, there are also specific dosages that should be used based on medical guidelines.

A: A team of independent, licensed doctors, pharmacists and other medical experts review and discuss the latest medical guidelines and research.  They decide which medications should be included in the Quantity Limit Program.

A: The pharmacist will let you know when you pick up your prescription at the pharmacy.  You may also call the Catamaran Member Services number on the back of your prescription card for more information.

A: If the Quantity Limit request is denied, your pharmacy benefit plan will still cover an amount up to the quantity limit for that medication. You will be responsible for the full cost of any amount above the quantity limit for your prescription.

A: Visit www.myCatamaranRx.com. You may also call the Catamaran Member Services number on the back of your prescription card.