My drug is not covered. What are covered alternatives?
Click here to view your health plan’s prescription drug list (PDL) of covered medications.
How do I get a 90-day supply of medication?
Your health plan covers a 90-day supply of medication through local Walgreens pharmacies. If you would like to participate:
- Your doctor can write you a new prescription for a 90-day supply.
- Your pharmacist can call your doctor to get a new prescription for a 90-day supply.
How do I get a 90-day supply of medication delivered to my home?
Your provider should write your prescription for a 90-day supply with three refills when appropriate (not a 30-day supply) and submit a request for home delivery.
- Fill out the new prescription mail-in order form. Then mail it along with your new prescription(s) to OptumRx, PO Box 2975, Mission, KS, 66201.
- Complete section one of the new prescription physician fax order form and give it to your provider. Your provider will fill out sections two and three, and then fax it along with your new prescription(s) directly to OptumRx at 1-800-491-7997.
- Ask your provider to send an electronic prescription to OptumRx.
Mail order benefits are only available to group health plan members. If you’re an individual health plan member, your local retail pharmacies can fill your prescriptions for up to 30 days at a time. This doesn’t affect any high-cost specialty drugs you may receive through the mail from BriovaRx.
How do I submit a prior authorization request?
Your provider can submit a prior authorization request online, by fax or mail.
- Fill out a prior authorization request form and submit it online.
- Be sure to include the following information or the request will be returned.
- Requested drug name
- Strength
- Quantity
- Duration of treatment
- Diagnosis
- Medical records (chart notes documenting prior therapy), allergies, lab results, etc.
- Clinical rationale (why covered or preferred drugs may not be appropriate)
- Fax your prior authorization request form to 1-800-997-9672.
- Mail it to Sierra Health and Life, Pharmacy Services, Attn: Medical Necessity, P.O. Box 15645, Las Vegas, NV 89114-5645.
What is CoverMyMeds?
CoverMyMeds assists providers with electronically submitting prior authorization requests to insurance companies. CoverMyMeds is NOT affiliated with Health Plan of Nevada. If you received communication from CoverMyMeds, you will need to contact CoverMyMeds directly.
How do I file an appeal?
You, your authorized representative, or your provider acting on your behalf and with your written consent may file an appeal either orally or in writing. A written, signed appeal request must follow an oral filing. Mail or deliver your written appeal to Sierra Health and Life, 2720 North Tenaya Way, P.O. Box 14865, NV017-3020, Las Vegas, NV 89114-4865.
How to file an expedited appeal?
You, your authorized representative, or your provider acting in your behalf may file an appeal either orally or in writing. Fax your appeal to 702-266-8813 or call Member Services toll-free at 1-800-962-8074, TTY 711. Weekdays after 5 p.m., weekend or holidays, call Customer Response and Resolution toll-free at 1-800-578-6757, TTY 711. Sierra Health and Life’s Pharmacy Services team does not process appeals.
If I am going on vacation or leaving the state/country for an extended period of time, how can I get my medications filled ahead of time?
We may offer a vacation override. A vacation override allows you to obtain medication in advance for extended vacations as outlined below whether it is within the U.S. or outside the country. Vacation overrides may be granted up to a 30-day supply for up to two vacations per year. If the date of your vacation changes, then a flight itinerary may be required. To request a vacation override, please call Member Services toll-free at 1-800-962-8074, TTY 711. You will need to provide the dates of your travel and the names of the prescription drugs you are requesting to be filled. Overrides may take up to 24 hours to process and entered for up to three days prior to their departure.
How do I synchronize my medication fills?
Please contact your pharmacist directly to request medication synchronization.
How/when can I contact Sierra Health and Life ?
Members can contact us toll-free at 1-800-888-2264, TTY 711, Monday through Friday, 8 a.m. to 5 p.m.
What is the difference between medical and pharmacy coverage of a drug?
Drugs covered under your pharmacy benefit tend to be oral medications/devices or injections that can be self-administered under the skin or into the muscle. A claim for payment is submitted to the health plan by the pharmacy. You, the member, is responsible for the copay for the drug only. The copay amount can vary by the tier level the drug is placed on by your health plan. Drugs covered under your medical benefit tend to be medications that require provider administration, are used to make a diagnosis or used during a procedure. A claim for payment is submitted to the health plan by the provider. The member is responsible for a copay for the office visit and coinsurance for the drug product. Coinsurance is the percentage of the drug cost that you pay after you have paid your deductible.
My pharmacy is having trouble processing my prescription claim through my insurance. What can they do?
If the pharmacy is having trouble submitting claims, ensure they are entering the following information appropriately: Member’s sex (male/female), member’s date of birth, Bank Identification Number (BIN) (a six-digit number on your health insurance card that tells the computer database at the pharmacy which health insurance provider is to receive the claim for your prescription), Processor Control Number (PCN) (a secondary number on your health insurance card that is used to route pharmacy claims to your health insurance provider), and group name.
BIN: 610279
PCN: 9999
GROUP: UNEVADA
What is a specialty drug?
A specialty drug is a medication created to target and treat complex medical conditions and rare diseases. These medications are often very expensive and require special handling. They can be taken by mouth, injected, inhaled or infused. Specialty drugs are designated on your plan’s drug list with the abbreviation “SP”. Your health plan requires specialty drugs to be filled at Optum Specialty Pharmacy (formerly BriovaRx) that offers additional support to help members with their specialty prescription products. Coverage of specialty medications are limited to a 30-day supply.
Are over-the-counter products (OTC) covered?
No, over-the-counter products are not covered by Health Plan of Nevada. The “limitations” and “exclusions” sections of your plan pharmacy documents exclude coverage of over-the-counter products.
Are generics different from brands?
When it comes to generic and brand name drugs, the main difference is the name and appearance. The U.S. Food and Drug Administration (FDA) requires generic drugs to have the same active ingredient, strength, dosage form, and route of administration as the brand-name drug. They are also developed and approved according to the same standards as brand name drugs ensuring both versions are identical in quality.
I need a new prescription or refills on an old prescription but I do not currently have a doctor. What can I do?
Please call Member Services toll-free at 1-800-888-2264, TTY 711. They can assist you with finding a new healthcare provider or see our list of providers.
The prescription written by my provider is too expensive. What is a lower cost alternative?
Please call Member Services toll-free at 1-800-888-2264, TTY 711. They can assist you with finding a lower cost alternative or view our prescription drugs lists. For your convenience, medications are grouped together based on their therapeutic category (i.e., anti-infectives, cardiovascular, etc.) and further separated into drug classes (i.e., antidepressants, contraceptives, etc.). To find a lower cost alternative, look for drugs in the same therapeutic category and drug class that are listed on the PDL at a lower tier level.
Why is the number of pills approved by my insurance different than what was requested by my doctor?
There are several reasons why your health plan approves a different quantity than what was prescribed by your doctor. A few of the most common reasons are:
- Your doctor requested a quantity that exceeds the plan’s limits
- Your doctor requested a dosage or frequency that exceeds the Food and Drug Administration (FDA) recommended dosage or frequency
- The requested drug is considered to be a specialty drug, coverage of all specialty drugs are limited to a 30 day supply
- Your plan only covers up to a 30 day supply per fill for all medications
- Your plan only covers up to a 30 day supply per fill at a retail pharmacy
What is a prior authorization? How do I get my drug approved? What do I have to do? Why does it take so long?
For some drugs, your doctor or other prescriber must get approval from us before you fill your prescription. If you don’t get approval, we may not cover the drug. In order to request approval of a drug, your doctor must fill out the prior authorization form and fax it to Pharmacy Services at 1-800-888-2264. Coverage of certain drugs may require chart note documentation of diagnoses, previously tried medications, or specific lab values for example. If this information is not provided by your doctor, we may request more information from your provider. This process may take up to seven days. You, as the member, do not have to do anything. If you have any questions on the status of the prior authorization request, call Member Services toll-free at 1-800-888-2264, TTY 711.
Why was my drug denied even though my doctor submitted a prior authorization?
There are several reasons your drug may have been denied even though your doctor submitted a prior authorization. Here are some of the most common reasons:
- You do not have the required diagnosis
- You have not tried and failed preferred alternatives
- Your doctor is requesting a quantity that exceeds the plan’s limit
- Your lab results are not in the required range
- Your doctor is not from the right specialty
- You are already on a therapy that is similar to the request medication
- You are not on the required therapy that is to be taken with requested medication
- You do not have a required comorbidity (condition when a person has 2 or more illnesses at the same time or one after the other).
- You have not discontinued therapies before initiating requested medication
- Your doctor has not provided the required information requested by the health plan
What’s the difference between deductibles, coinsurance and copays?
When both you and your health insurance company pay for your health care expenses, it’s called cost-sharing. Deductibles, coinsurance and copays are all examples of cost-sharing.
- A deductible is the amount you pay before your health insurance begins to pay. This amount will vary by health plan.
- Coinsurance is the amount you pay as your share toward a claim. It is the percentage of the drug cost that you pay after you have paid your deductible.
- A copay is a fixed amount you pay for a drug. The amount can vary by the tier level the drug is placed on by your health plan.
If you need assistance determining your plan’s deductible, coinsurance and copays, call Member Services toll-free at 1-800-888-2264, TTY 711, or sign in to the online member center.