PBM Services
Welcome, CommuniCare Family of Companies Employees!
Our customer care team is dedicated to serving you.
Setting up and navigating your member portal
Learning which pharmacies are in network
Signing up for pharmacy home delivery
Ensuring pharmacy errors are corrected, and claims are properly processed and paid
We can help with:
Navigating copays and covered medications
Fixing eligibility issues
Prior authorizations
CommuniCare Medication Copay Structures
CommuniCare offers three benefit plans.
1) Preferred Provider Organization (PPO)
Pay prescription cost if it’s less than copay.
| Pharmacy | ACA / Generic / Brand / Non-Preferred / Specialty |
|---|---|
|
Retail (30-day supply) |
$0 / $20 / $50 / $150 / 25% max $300 |
|
Home Delivery (90-day supply, specialty has 30-day supply limit) |
$0 / $40 / $100 / $300 / 25% max $300 |
2) High Deductible Health Plan (HDHP)
ACA list is $0 copay (30% co-insurance not required).
Member pays 100% of drug cost until deductible is met.
30% Co-insurance starts after deductible is met.
Medications are fully covered by plan after max out-of-pocket limits are met.
| Pharmacy | ACA / Generic / Brand / Non-Preferred / Specialty |
|---|---|
|
Retail (30-day supply) |
30% Co-Insurance |
|
Home Delivery (90-day supply, specialty has 30-day supply limit) |
30% Co-Insurance |
3) Health Path Plan (HPP)
Pay prescription cost if it’s less than copay; specialty drugs are not covered.
| Pharmacy | ACA / Generic / Brand / Non-Preferred / Specialty |
|---|---|
|
Retail (30-day supply) |
$0 / $5 / $30 / $60 / Not Covered |
|
Home Delivery (90-day supply, specialty has 30-day supply limit) |
$0 / $10 / $60 / $120 / Not Covered |
Questions about your medication cost?
Why Should You Review Your Medication Formulary?
Your drug formulary (the list of medications available on your plan) was designed by a team of physicians and pharmacists to provide you with safe and effective medication choices. Be sure to check the formulary every year during the open enrollment period, since changes are always being made to drug coverage. If you’re choosing an insurance plan for the first time, look for one that covers the medications you are currently using.
Sign Up for Pharmacy Home Delivery
We make medication access easy for you. We deliver 90-day supplies of brand and generic medications directly to your doorstep to save you time and money. We also deliver 30-day supplies of specialty medications. Copays are generally less expensive when you use mail order and signing up is easy.
When you need a prescription or a refill, ask your prescriber to send your prescription(s) to:
Northwind Pharmaceuticals
4838 Fletcher Avenue
Indianapolis, IN 46203
NPI – 1700321312
Need Help?
As a reminder, our customer care team is available Monday – Friday: 7 a.m. to 8 p.m. (ET) and Saturday and Sunday: 10 a.m. to 6 p.m. (ET).
Call 1-866-490-3636 for assistance.
Pharmacy Concierge Program
If you are prescribed an expensive specialty medication, the Pharmacy Concierge program can help you save money. A team of pharmacy specialists will work with you, your doctor, and your pharmacy to help make specialty medications more affordable. The Pharmacy Concierge program is offered by CommuniCare to work on your behalf. Enrolling in the program could eliminate your out-of-pocket costs.
Prior Authorization
What is a Prior Authorization?
Certain prescriptions require pre-approval, or prior authorization, before allowing the medication to be paid for by the benefit plan. Check the formulary document to see if your medication requires a prior authorization. PBM Services aims to review all prior authorizations within 24 hours, but it may take up to 72 hours or more if documentation is incomplete or if we need to contact your prescriber/provider’s office with questions. Failure to obtain prior authorization could result in a lack of coverage for the medication.
How to Obtain a Prior Authorization
To start the prior authorization process, the prescribing provider (or their designee) fills out the prior authorization form and provides it to the PBM Services team via fax (317-458-2054) or secure email (pa@nwpharma.com). PBM Services is also available to prescribers at 1-866-490-3636 Monday – Friday between 8 a.m. and 5 p.m. (EST) The outcome of the prior authorization request will be mailed to the patient and faxed to the prescriber.