Pharmacy Benefits Information
WHAT ARE MY PHARMACY BENEFITS?
Members of the Sandhills Center Tailored Plan have pharmacy (medication) benefits through our partner Perform Rx. Starting April 1, 2023, you may use your Sandhills Center member ID card for pharmacy benefits. You can get medications, diabetic supplies, and other covered items from local pharmacies. PerformRx has offered pharmacy benefits since 1999. It is a valued partner in serving Sandhills Center members.
For benefit information, call Member & Recipient Services: 1-800-256-2452 (TTY: 1-866-518-6778)
You can also have your medications delivered to your home if you have trouble getting to your local pharmacy. All pharmacies are allowed to mail prescriptions if they want to offer that service. Talk to your pharmacy and ask them if they can mail medications to you. If you need your medications mailed to you, but your pharmacy does not provide that service, Sandhills Center has many pharmacies that can mail your prescriptions to you at no extra cost.
If you would like Sandhills Center to help you find a pharmacy that has mail or delivery service, or if you have any other questions about your pharmacy benefits, contact Member & Recipient Services at 1-800-256-2452 (TTY: 1-866-518-6778).
PREFERRED DRUG LIST
Medicaid has an open formulary. That means most medications are covered. However, some medication groups have a preferred drug that is covered instead of others. A generic drug may be preferred and covered over a branded medication. Members can see if their drugs are covered, and when generics are available, by looking at the Preferred Drug List or by using the Drug Formulary Lookup Tool, below:
You can check how much a medication will cost by clicking here: [link coming soon]
PRIOR AUTHORIZATIONS
When medications are "non-preferred," or not covered, sometimes they can be approved when a physician goes through the “prior authorization” process. Prior authorization is a decision made by your health plan that lets you receive a health care service or prescription drug that is medically necessary. Prior authorizations must be made in advance of receiving the service or medication. If a member has not found success using two medications in a preferred group, and/or has a specific disease diagnosis, your doctor may be able to help get a medication covered through the prior authorization process. Your doctor may use the information here to see if prior authorization is possible based on your needs:
Prior Approval Drugs and Information for Physicians
Members can request a prior authorization here (link is currently inactive until closer to Tailored Plan launch)
HOW TO GET YOUR MEDICATION DURING A DISASTER OR EMERGENCY
It is always a good idea to have a plan in place in case of a disaster or emergency. The best way to be ready with medications is to always have one to two weeks' worth on hand. Often, disasters and emergencies are over in a couple of weeks. Planning ahead will help you so you do not run out.
Save an empty bottle of each of the medications you currently use. In times when electricity is out, pharmacies can read prescription information based on the label. That will help them to fill your prescriptions. If you are on vacation, away from home, or displaced by a disaster, pharmacies can send your prescription information to a pharmacy near you.
When in doubt, ask a pharmacist. Pharmacists have emergency plans, too. They will be able to solve problems based on current events and needs. Sandhills Center’s pharmacy partner PerformRx will assist members to get early refills for vacation supply, lost/stolen supply, leave of absence supply, national disaster supply, delayed mail-order supply, and spilled medication supply. Call Member & Recipient Services if you have questions: 1-800-256-2452 (TTY: 1-866-518-6778).
OPIOID MISUSE AND PREVENTION TREATMENT PROGRAM
Opioids include medications such as oxycodone, hydrocodone, morphine, and others. The Sandhills Center Tailored Plan knows that prevention (addressing opioid misuse) is important. We work closely with members, recipients, providers, law enforcement, and community partners. It is Sandhills Center’s goal to educate our members and the community to prevent and reduce over-prescribing. We also want to increase access to naloxone (Narcan) and expand treatment and recovery options.
People who are at risk of opioid misuse are:
- Those with substance use disorder.
- Individuals who ask for early refills while taking certain medications.
- Those who have two or more prescriptions for Narcan.
- People who continually use opioids, or have multiple physicians who are prescribing opioids for them.
Sandhills Center will provide individual, group, or family therapy to help reduce the use of opioids. Members who are at risk will be assigned to the Lock-In Program which allows only one pharmacy and one prescriber for opioids and other controlled substances. Sandhills Center will limit the strength and length of treatment with opioid pain medications, and make naloxone available for safety. Members will have access to medication-assisted treatment (MAT) for opioid use disorder.
Questions about Opioid Misuse Treatment or the Lock-In Program? Call Member & Recipient Services: 1-800-256-2452 (TTY: 1-866-518-6778), or talk to your doctor.
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