Prescription Override Process for SSHE Employee Groups

The procedure for requesting prescription drug override(s) was revised on March 8, 2010. The revision was necessary to reduce the amount of personal health information (PHI) an employee/annuitant is required to share with the System Benefits Office or the universities in order to request the prescription drug override.

Whenever possible, if the employee/annuitant has sufficient lead time, they should be encouraged to use the mail order feature through Highmark/Express Scripts to obtain up to three (3) months of prescriptions.

The new procedure will be as follows:

1) When a member needs to request a pharmacy override, they should call the Highmark Member Services toll free number located on their Identification cards and indicate that they need an override (as opposed to either contacting their university Benefit Coordinator or the System Benefits Office with the specifics of their override request).

2) The Highmark representative will obtain the required pharmacy override details from the member, who should be prepared with the needed information. This information will include:

a) Employee/annuitant name
b) Highmark identification number (located on their Identification card)
c) Name of member taking the medication
d) Name of the medication, including strength and dosage
e) Name of pharmacy
f) Date leaving the country
g) Date returning

3) The Highmark representative will send a secure email (providing only the non-PHI information) to request approval from the System Benefits Office. The Highmark representative will need to have approval from the System Benefits Office before proceeding with the pharmacy override.

4) The System Benefits Office will research to confirm that the employee/annuitant is eligible for the requested prescription override timeframe. The maximum amount of time a pharmacy override will be approved will be six (6) months or 180 days. There may be exceptions given certain situations where additional information may be requested by the System Benefits Office in order to review the pharmacy override request. Below are typical examples of when a pharmacy override may be requested.

a)A member is requesting a pharmacy override since they are leaving the country for the summer months and does not have sufficient lead time for mail order service;

b)A COBRA member is requesting the pharmacy override. It will be necessary for the COBRA premium to be paid for the amount of time being requested for the pharmacy override (i.e., if the COBRA participant is requesting an override for a 6-month period, COBRA premiums need to be paid for the entire 6-months of coverage);

c)A member is on a Leave Without Pay With Benefits status. The employee contributions must be paid for the entire period for which the pharmacy override is being requested;

d)A member requests a pharmacy override for more than 6 months and is on a paid sabbatical leave with their university. The pharmacy override may be approved for the requested timeframe, but not to exceed twelve (12) months or 365 days;

e)A member requests a pharmacy override for more than 6 months due to being enrolled in an institution of higher education outside of the United States. The pharmacy override may be approved if documentation is provided that substantiates their enrollment at the institution for the requested pharmacy override period, but not to exceed twelve (12) months or 365 days;

5) After the System Benefits Office has researched eligibility, a response is sent via secured email to Highmark.

a) For approvals, the Highmark representative will forward the request to the pharmacy area (Express Scripts) for processing. The member is contacted by the Highmark representativeand instructed when the medication should be available for pickup.

b) For denials, the Highmark representative contacts the member to relay why the request was denied. The System Benefits Office may deny a pharmacy override request for more than 6 months, but instead approve for only 6 months.

Original Pharmacy Override Process (Frequency: Ad Hoc)

Brief description why process is performed: An employee, annuitant, or dependent needs a prescription days’ supply which is greater than the usual supply. The maximum days supply that can be authorized is 6 months. If employee has been approved for sabbatical with the university, the override can be allowed for up to 1 year. If an employee does not return to work after the sabbatical, the salary that was paid during that timeframe is owed back to the university.

Steps:

  1. A customer service representative from Highmark emails PASSHE.
  2. In the email is the following information:
  3. Reason for override
  4. Name of employee / annuitant
  5. Name of patient
  6. Date they are leaving
  7. Date they are returning
  8. Drug Name
  9. Need to confirm in SAP the information that was provided by Highmark. Also, need to confirm that the employee is not on sabbatical or another personal leave. If on sabbatical, need to confirm with campus prior to approval.
  10. Go to benefits tab in SAP, health plans, overview, and select most current health plan.
  11. If a dependent, click on the dependents tab. It will display all the dependents that have the prescription benefit.
  12. If everything is confirmed, send an approval email back to Highmark. “Thanks this prescription override is approved.”
  13. If everything is not confirmed, request more information from Highmark until it can be confirmed by SAP.

1