FAQs

PHP's ID number is 12399.  Please see the HIPAA section of our site for further information regarding electronic claim submission.

The time to credential varies based upon the completeness of the application and the return of all required documentation to our Credentialing Coordinator.

PHP provides each contracted provider fee schedule information for their top 10 codes.  To obtain the reimbursement simply provide PHP with a list of CPT codes along with the billed.  Your request can either be faxed to Provider Services at (260) 432-0493, or emailed to us at providerservices@phpni.com.

Simply complete the Provider Change Form.

To add a physician to a contract, PHP requires the completion of the Provider Participation Application.

PHP does utilize CAQH for credentialing.  The Provider Participation Form gave you the option to use the CAQH database or submit a paper application.

PHP does contract for ancillary healthcare providers if they are employed by a provider practice currently contracted with PHP.  We do not contract directly with these providers.

The Price a Medication tool is located within your member account. From the left hand menu, go to Pharmacy > Price a Medication.

• Stop and Compare drug pricing from location to location as prices can change monthly
• Swap your prescriptions for over-the-counter drugs, if possible.
• Use generic drugs, whenever possible.
• Look into mail order, it could save you money and time.

When possible, you should always choose an in-network doctor, hospital, or facility. Use our Find Care search tool to find the facility right for you.

Getting the most out of your healthcare insurance coverage is important. If you understand your pharmacy benefit and how it works, you can use it to save money on the cost of your prescriptions and thus maximize your benefit.

It is important to work with your doctor on how best to maintain your good health and how to successfully manage any existing health conditions you may have.

When medicines are needed to treat a health condition, be sure that you understand how to get the most effective drug treatment while controlling the cost of your prescriptions.

Many prescription drugs actually cost the same amount, regardless of the strength, meaning that a 20mg pill of a certain medication could cost the exact same amount as a 40mg pill.  Specific medications are appropriate for tablet splitting and can offer immediate out-of-pocket savings.

Health plans use formularies to manage the cost of pharmaceutical healthcare.  Formulary guidelines and protocols are used to encourage doctors to prescribe according to a predetermined therapeutic strategy developed by local health professionals.

Our Customer Service Department can provide drug formulary information, or you may check for formulary information listed at www.phpni.com.  All PHP participating doctors and pharmacies automatically receive a copy of the drug formulary each year along with updates throughout the year.

For more information, and for a complete listing of the pharmacy providers in our service area, call PHP Customer Service or visit the pharmacy and network sections of our website at www.phpni.com.

Some medications require the use of an alternate prescription drug within a specified number of days before they can be covered.  This alternate prescription process is referred to as Step Therapy.

Certain medications have a status of Prior Authorization Required (PAR).  If your doctor wants to prescribe a PAR drug, he or she will submit a request for approval before the drug can be dispensed as a covered benefit.  If your pharmacist receives notification that a drug you were prescribed requires prior authorization, ask your pharmacist to contact us.

A generic drug is a copy of the original drug that is no longer protected by a US patent.  It is typically a drug that has been available for more than 20 years.  Generic drug manufacturers are allowed to produce these medications after the patent for the original brand has expired.  Generic drugs are less expensive than brand-name drugs since generic manufacturers have not had to invest in the research and development of the drug when it was brought to market.  Substituting a generic drug for a brand-name drug usually has no adverse effect.

A formulary is a list of prescription drugs that PHP encourages our doctors to prescribe when appropriate.  This formulary was developed with the help of area doctors and pharmacists.  The formulary is updated quarterly and may change at any time.

A tiered copayment benefit means there are several possible copayment levels. A member’s copayment is based on the prescription drug being purchased. For example, the first tier represents a preferred generic drug that has the lowest copayment.

Traditional Drugs

• Tier 1 Preferred Generic: Covered drugs that are no longer protected by a drug company patent allowing other drug companies to manufacture equivlant versions of the same drug at a reduced cost. 
• TIER 2 Non-Preferred Generic: Similar to Tier 1 covered drugs, but available with a higher copayment. 
• TIER 3 Brand Formulary: A list of brand-name drugs that PHP participating network doctors are encouraged to prescribe, when appropriate, for treatment of a medical condition. 
• TIER 4 Brand Non-Formulary: Covered drugs that are not included in the formulary listing. You may obtain non- formulary brand-name drugs with a higher pharmacy copayment. 
• TIER 5 Specialty Drugs: Specialty drugs are generally injectable, high-cost medications, which you may obtain through our specialty pharmacy, unless administered by a PHP network provider. 

If you or your doctor want a brand name drug when there is a generic drug available, you will have to pay more than the formulary or non-formulary brand copayment.

Speciality Drugs

• Tier 1 Preferred Speciality Drugs*: These medications can be injectables or orals that are extremely expensive, must be fulled at a specialty pharmacy, and may need special instructions and handling.
• TIER 2 Specialty Drugs: These medications can be injectables or orals that are extremely expensive, must be fulled at a specialty pharmacy, and may need special instructions and handling. 

If the drug is covered by PHP, we will allow the brand.  However, the member will be responsible for the cost difference between the brand and the generic in addition to the normal copay.  This is known as an ancillary charge.

If traveling and a medical emergency occurs that requires prescription medication, simply take the prescription to one of our 40,000 participating pharmacies across the nation, including Walgreens, CVS, and Wal-mart Pharmacy locations.  If unable to locate a participating pharmacy, take the prescription to a local pharmacy.  The member may be required to pay the full price of the prescription.  When they return home, submit the pharmacy claim for reimbursement.  In order for PHP to consider the claim, they must include the receipt, name of the medication, quantity, diagnosis, date of service, and member name and number.

A doctor may prescribe a prescription drug that is not on the PHP formulary.  The member has the option to receive the non-formulary medication at a higher pharmacy copayment or to ask the doctor for a formulary medication.

Specialty drugs are generally injectable, high-cost medications that have special handling requirements or require special training before use.  These types of medications may be obtained through our specialty pharmacy, unless administered by a participating PHP network provider.  Depending on the benefit plan, specialty drugs may have a different copayment and out-of-pocket expense than the three-tier pharmacy structure.

Yes.  We use Express Scripts, a mail service pharmacy program that provides fast and convenient delivery of maintenance medications directly to your home for up to a 90-day supply.  You pay only the copayments as determined by your benefit plan, just as if you were receiving a prescription filled at the local pharmacy.  Express Scripts can be reached at (800) 557-3952 or visit the Express Scripts Pharmacy Web site at www.express-scripts.com.  To obtain a mail order form or for information about the mail order program, please contact our Customer Service Department.

By asking the doctor if a generic drug is available for the treatment of a medical condition, the member may become eligible to take advantage of savings by lowering the pharmacy copayment.  To allow for generic drug substitution, ask your doctor to use the signature line located on the right side of the prescription.

Yes, but members are required under their contract to pay the applicable cost sharing, which includes the Deductible, Copay, or Coinsurance as shown on the Schedule of Benefits. The requirement to pay the applicable cost sharing (Deductible, Copay, or Coinsurance) cannot be waived by a provider, a pharmacy or anyone under any “fee forgiveness,” “no out-of-pocket,” “discount program,” “coupon program” or similar arrangement. If a provider, pharmacy or third party (other than family) waives, discounts, reduces, or indirectly pays the required cost sharing (Deductible, Copays, Coinsurance) for a particular claim, the applicable cost sharing met by the member on the claim will be reduced to reflect the amount of such waiver, discount, reduction, or third party payment. The total amount accumulated toward any overall deductible and/or maximum out-of-pocket amounts will also be reduced by the amount of any discount.

Some medications may be subject to quantity level limits based on the manufacturer's packaging insert.  These Quantity Limits are designated in the Drug Formulary by (QL) next to the medication name.  The purpose of these maximum quantity limits is to ensure the proper billing of products.  It also encourages the use of therapeutically indicated medication regimens.

At our Web site, www.phpni.com, members can refill mail order prescriptions and check for possible drug interactions.