How else can we help you? This page contains helpful information and resources related to your prescription drug benefit.
Drug Coverage and Pharmacy Access
The information below explains which drugs are covered by your plan and how to locate participating pharmacies and mail-order pharmacy services available to you.
The drugs listed below are what is covered under your plan when prescribed and obtained according to plan guidelines. Note, some drugs require you (and your provider) to get prior authorization or requires step therapy.
Your plan includes access to a broad network of pharmacies both locally and nationwide. For a complete list of participating locations, please refer to the pharmacy directory.
Find a Participating Pharmacy Near You
In-network coverage: In-network refers to the network of providers that participate with your plan. If you choose to access services in network, you will receive your plan's negotiated rates with those providers.
Out-of-network coverage: If you visit a non-participating provider or hospital, your service is subject to your deductible, plus any copayment and/or coinsurance and balance billing.
You may be eligible to have a 90-day supply of your maintenance medication delivered to your door through a mail order pharmacy. These pharmacies will ship your medication at no cost, which could save you time and money.
More information: Mail Order Pharmacy
Prior Authorization and Appeals
Prior authorizations and appeals ensure medications are clinically appropriate and cost-effective by requiring review before certain drugs are covered and providing a process to request an appeal if coverage is denied.
Prior authorization (also referred to as preauthorization or pre-approval) is the process of obtaining coverage approval for certain prescription drugs. To encourage and promote the safe use of medications, certain prescriptions may have to be approved for individual use prior to coverage.
In order to obtain a prescription that requires prior authorization, certain criteria must be met. To obtain prior authorization, the prescribing provider submits a request form to Pharmacy Benefit Dimensions.
Work with your provider to fill out a: Prior Authorization Form
Some common prescription drugs require prior authorization due to their wide range of uses and/or to ensure safety, including authorization for quantities which are higher than the FDA recommended daily dose or duration of therapy or for quantity limitations are those for treatment of migraine headaches and sleep disorders.
An appeal is the type of complaint you make if you disagree with a coverage decision we have made. A standard decision is made within 30 calendar days, but an urgent appeal can be filled by your treating provider.
Work with your provider to fill out an: Appeal Form
Ask your pharmacist to contact Pharmacy Benefit Dimensions' Pharmacy Help Desk at 1-800-993-9898 or have them email script@pbdrx.com.
Claims, Deductibles, and Payments
The section below provides information related to how your prescriptions are processed, covered, and paid.
A request for a benefit made by you or your provider to your plan for prescriptions or services you think are covered.
Claims adjudication is the process that a pharmacy benefit manager (PBM) uses to evaluate a prescription drug claim that is typically sent by a pharmacy. This includes checking your eligibility, determining coverage and reimbursement, calculating copays, reviewing for utilization for management requirements (like quantity limits or prior authorization), and ensuring the prescription isn’t filled too soon. This ensures that claims are processed quickly, accurately, and according to plan design.
A deductible is the amount you owe for healthcare services that your plan covers before your plan begins to pay. For example, if your deductible is $1,000, your plan won’t pay anything until you’ve met your $1,000 deductible for covered healthcare services subject to the deductible. The deductible may not apply to all services.
A copayment is the fixed amount (for example, $15) you pay for a covered prescription or service. The amount can vary by the type of covered healthcare service.
Coinsurance is your share of the costs of a covered prescription or service, calculated as a percent (for example, 20%) of the allowed amount. You pay coinsurance plus any deductibles you owe.
Drug Safety
Pharmacy Benefit Dimensions strives to provide safe access to your medications while addressing any specific safety concerns.
When a new drug is approved by the U.S. Food and Drug Administration, Pharmacy Benefit Dimensions reviews it in detail using physicians’ and pharmacists’ input to determine potential safety rules and therapeutic concerns. We communicate this information to you via educational mailings and client meetings.
Yes. At the time of a pharmacist dispensing, we electronically review your prescription and your current medication profile in order to identify any possible safety issues.
Yes. After dispensing, we may review both historical data and the latest information provided to us through our national prescription drug database. In addition, we receive timely alerts of new safety information on drugs and medical devices from the FDA. The alerts contain information that may impact both treatment and diagnostic choices for both you and your provider.
In addition, programs are in place to identify areas where certain drugs are taken too frequently and offer recommendations on drug alternatives. We offer drug compliance programs for several conditions including diabetes, asthma, and cardiovascular disease.
Contact our Member Services Department
Have a question? Our Pharmacy Benefit Dimensions Member Services Department is here to help with questions regarding your plan, benefits, etc.
