Our Vendors

PRESCRIPTION DRUG BENEFITS

The OU Health Plan utilizes Navitus as the Plan’s Prescription Benefits Manager (PBM).

What is Covered? – The OU Plan covers drugs that must be prescribed by a Professional Provider, and approved by the FDA for the treatment or for specific diagnosis or condition. The drug must also be Medically Necessary treatment of the condition for which the drug is prescribed, and not Experimental and Investigational as defined in the Plan Document, unless otherwise required pursuant to an external appeal. Insulin and oral agents for controlling blood sugar are provided through the prescription drug program, as are other diabetic supplies.

Generic equivalents of prescribed drugs will be provided unless specifically prohibited by the prescribing physician. If you choose to obtain a brand name drug when a generic equivalent is available, you will be responsible to pay the additional excess charges.

How the Program Works. – If you purchase drugs at a participating (in-network) pharmacy or through the mail order pharmacy, your co-payments depend upon the category of the drug purchased. Generic drugs cost the least, while preferred drugs and non-preferred drugs are more expensive. For a list of preferred drugs (PDL), see the Pharmacy Benefit Manager’s website at navitus.com/members.

Using the Mail Order Pharmacy. – Save time and money by using Costco Pharmacy to have your prescriptions mailed directly to you. To get started, simply register at pharmacy.costco.com or call 800-607-6861. Once your prescriptions have been transferred, Costco Pharmacy will mail them to you within five business days.
You do not need to be a Costco member to use Costco Pharmacy.

The table below shows your co-pay for drugs, depending on the type of drug (generic, preferred or non-preferred) and whether you obtain the drug at a retail drug store, through the mail order pharmacy or at your local drug store.

Example below. See Plan Document for additional information.

If you have any questions you can speak to our Customer Care team 24 hours a day, 7 days a week. Just call 855-673-6504 toll-free. We can help answer your benefit questions.

HealthCare Strategies, Inc.
(1-800-582-1535)

HealthCare Strategies (HCS) is a managed care company that the OU Health Plan has contracted with to assist Plan members in making informed decisions about their health care. HCS is dedicated to helping the OU Health Plan members improve their health and wellness through a number of programs.

HCS provides member access to Care Counselors, who are Registered Nurses, 24 hours a day, 365 days a year. They provide callers with toll-free, confidential health care advice and information. The programs are based on the premise that informed patients make better and more cost effective health care decisions.

HCS provides several programs to assist members.

The Medical Information Helpline (1-800-582-1535) assists members when there are questions or concerns about: medical care; side-effects’ how to locate a qualified health care provider; hospitalization is required; an outpatient procedure; a drug or alcoholic concern; or any time information or answers on medical services or procedures are needed.

The HealthReach Program (1-800-582-1535) gives members personal assistance to help understand and manage specific medical conditions or minimize potential side effects of prescription drugs. The HealthReach Program does not make decisions for members but provides information and clarification to assist in making appropriate decisions.

The MaterniCare Program (1-800-582-1535) is based on proactive communication with expectant mothers. Expectant mothers should call to enroll within 30 days of the diagnosis of pregnancy in order to receive the full benefit of the MaterniCare Program. The participating mother is provided a personal RN-MaterniCare Counselor who can be reached through a 24 hour information line. Customized educational information is provided to the mother throughout her pregnancy.

The Large Case Management Program (1-800-582-1535) is there for members who may have a catastrophic injury or chronic care needs. The Case Counselor becomes the primary coordinator, patient advocate and counselor for the member to ensure that the member receives the best quality of care available.

Remember that HealthCare Strategies Services Programs are provided without cost to members enrolled in the OU Health Plan; provide confidential & specialized information to help individuals to achieve maximum health; cannot make decisions for you; can be accessed 24 hours a day, 7 days a week.

Quantum Health Solutions, Inc.
Quantum Health Solutions, Inc., is the comprehensive behavioral health care management program for benefit-eligible employees of OUSDHP. Quantum offers a full range of specialty behavioral health services provided by a culturally diverse network of licensed community behavioral health programs, clinics and private psychiatrists, psychologists, and therapists/counselors.

Some people seeking behavioral health services require only basic counseling services, but for those who are in need of more extensive treatment, OUSDHP medical benefit offers an range of behavioral health services. Quantum offers centralized diagnostic and referral functions that include identification of the most clinically appropriate and cost-effective level of intervention.

Our team of professionals monitors all phases of and during the treatment process, starting with the initial request for treatment. Case managers assess the necessity and appropriateness of treatment, develop a plan for monitoring care and approve provider treatment plans with internal protocols and criteria for clinical care.

Our on-going review process monitors treatment for frequency, duration and efficiency. Alternative modalities of care are developed and recommended as circumstances dictate. We work with you to coordinate treatment planning, which provides for early identification of effective alternatives, allowing better management of care transition from acute to palliative care. During aftercare monitoring, the case manager assists the patient in making a complete transition from treatment to normal living activities. This stage guards against relapse and inappropriate re-entry into treatment.

Pre-certification process starts by calling 888-214-4001. Access to in-network coverage for mental health and substance abuse treatment, either inpatient or outpatient is through Quantum. You can contact one of our network providers and schedule an appointment, and contact Quantum to take the next step. The Quantum Case Manager, after speaking with you about your individual and special concerns, will prepare the authorization for the most appropriate service(s) to meet your specific needs. You have access to the following services:

Outpatient benefits will allow members to access care with Quantum NET and Anthem  psychiatrists, psychologists and social workers for in-network coverage. *Non pre-certified and out-of-network provider claims are reimbursed at the out-of-network rate.*

Inpatient benefits will allow members to access care to Quantum NET and Anthem facilities for treatment when medically appropriate. It is important to remember that you must call Quantum for admission pre-certification. Emergency and crisis treatment require you to contact Quantum the following business day for retroactive pre-certification. *Non pre-certified and out-of-network provider claims are reimbursed at the out-of-network rate.*

Claim coordination with the plans claims administrator occurs daily with the Quantum Case Management team.  If you have any questions regarding the claims process, call the plan claim administrator and if additional assistance is warranted call the Quantum Case Manager at 888-214-4001 for further assistance.

Plan pays 100% for covered Infertility Specialty Medications when obtained from Schrafts II Pharmacy at 855-724-7238 or schrafts2.com.