Member Resources

Contact our Guide Team

Need help with something not listed on this page or have additional questions? Please call us at 1-866-840-1877 24 hours a day/7 days a week or reach us through the WithMe Health Chat feature of our App. The Guide Team is here to help with questions about benefits and your medications, including:

• copays, deductibles, max out-of-pocket expenses
• pharmacy network
• claims processing, submission, and payment status
• benefit coverage/eligibility
• coverage decisions & appeals
• complaints
• any questions about your medications or treatment

WithMe Health App

The WithMe Health App is designed to help you get the most out of your WithMe Health benefit and tailored specifically for you. To download the app, visit go.withmehealth.com from your smartphone browser or search for WithMe Health in the Apple App Store for iOS devices or Google Play Store for Android devices. Interested in learning more?

• WithMe Health App Overview

Find a Pharmacy

If you need to find a pharmacy in your area that is part of the WithMe Health pharmacy network or have questions regarding your mail order or specialty pharmacy, please call 1-866-840-1877. You may also use the WithMe Health mobile app to search for in network pharmacies in your area.

Formulary Information

WithMe Health’s formulary (list of covered drugs) is developed & maintained by a Pharmacy & Therapeutics (P&T) Committee. The P&T Committee is made of practicing pharmacists and physicians that have a wide variety of specialties. The formulary is reviewed and updated as new drugs enter the marketplace or when new drug information becomes available. The Committee bases their decision to place a drug on the formulary on the following items:

• safe use of the medication
• clinical efficacy of the medication
• therapeutic need

Cost is considered only after these factors are taken into account. Following the formulary is important for improving quality of care and managing health care costs. Generic drugs are covered on the formulary and are a way to help control your out of pocket costs. You should consult with your prescriber to determine if a generic drug is right for you. Some plans require you to use generic drugs when available.

PLEASE NOTE: The list(s) below may be subject to change. Not all drugs listed are covered by all prescription-drug benefit programs. For specific questions about your coverage, including your cost share, less expensive alternatives, as well as if you have a mandatory mail order benefit, please call the WithMe Health Guide Team at 1-866-840-1877 or refer to your Summary Plan Document (SPD).

• 2021 WithMe Health Premier Plus Formulary
• Formulary Changes
• Affordable Care Act Preventive Drug List
• Prior Authorization Drug List
• Quantity Limit List

Coverage Decisions & Appeals

A coverage decision is a decision we make about your benefits and coverage. This includes prior authorization requests or exception requests for drugs that are not on the formulary or are on the formulary but have a quantity limit or step therapy.

If we make a coverage decision and you are not satisfied with the decision, you can “appeal” this decision. An appeal is a formal way of asking us to review and change an adverse coverage decision we have made.

When you appeal a decision the first time, this is called a Level 1 appeal. In this appeal, we review the coverage decision we made to check to see if we applied the coverage rules properly. Your appeal is handled by a different reviewer than the one who made the original unfavorable decision. When we complete the review, we will give you our decision.

If we say no to the Level 1 appeal, you can ask for a Level 2 appeal which is conducted by an Independent Review Organization that is not connected to us. If you are not satisfied with the decision at the Level 2 Appeal, you are able to bring a civil action under section 502(a) of ERISA following an Adverse Benefit Determination on review. (Note: refer to your Summary Plan Document(SPD) for more information regarding your various appeal levels, some plans offer more than two appeal levels)

You may request a coverage decision the following ways:

• You or your prescriber may call our Med Guide Team
• Your prescriber can fax a completed prior authorization/exception form to us
• Your or prescriber can mail WithMe Health the completed prior authorization/exception form

You or your prescriber may request an appeal up to 180 days after we issue an adverse (denied) coverage decision.

• Standard appeal requests, which are reviewed and decided in 30 calendar days of receipt of the request, must be submitted in writing by fax or mail.
• Expedited appeal requests, which are reviewed and decided within 72 hours of receipt of the request, may be submitted in writing or over the phone.

Contact Information:

Mail: WithMe Health
ATTN: Member Services
204 E 2nd Ave #337
San Mateo, CA 94401
Fax: 1-866-678-8301
Phone: 1-866-840-1877

Below you'll find various prior authorization/exception forms for your prescriber to complete.

• General Prior Authorization Request Form
• Cystic Fibrosis PA Form
• Descovy/Truvada PA Form
• Erectile Dysfunction PA Form
• Hemophilia PA Form
• Hepatitis C PA Form
• Hereditary Angioedema PA Form
• Long Acting Opioids PA Form
• Praulent_Repatha Form PA Form
• RA/Crohn's/Psoriasis PA Form
  
• Weight Loss PA Form
• Acthar Non-Formulary Exception
• Non-Formulary Exception
• Quantity Limit Exception
• Step Therapy Exception

State Specific Prior Authorization Forms

• State of California Prior Authorization Form
• State of Colorado Prior Authorization Form
• State of Illinois Prior Authorization Form
• State of Iowa Prior Authorization Form
• State of Louisiana Prior Authorization Form
• State of Massachusetts Prior Authorization Form
  
• State of Oregon Prior Authorization Form
• State of Texas Prior Authorization Form

Other Documents & Forms

• HIPAA Authorization Form
• Appointment of Authorized Representative Form
• Direct Member Reimbursement (DMR) Form

Members who have paid out of pocket for prescriptions during eligible periods should complete the Direct Member Reimbursement form to request reimbursement. Please send completed HIPAA and DMR forms by fax to 1-866-834-4614.

or by mail to:

WithMe Health
ATTN: Member Services
204 E 2nd Ave #337
San Mateo, CA 94401

Health Information

Drug Information

To learn more about your medication(s) click Here.

WithMe Health Medication Guidance Program

Our mission is to help members navigate and manage medication related healthcare needs by our team of experienced Guides and mobile apps. WithMe Health keeps track of how members are doing, helps to coordinate care with their prescribers and other support entities involved in their care, and provides applicable cost savings opportunities and additional resources for educational and financial assistance.

The program is available to you through your employer-sponsored health benefits at no cost to you. We would like to make sure that you understand all the benefits of the program. If you have any questions or would like to opt-out of the program, please contact us at 1 (866) 840-1877 or through the chat function on our app. Our hours of service are Monday through Friday 8am - 10:30pm EST , Saturday and Sunday 9 am - 5:30pm EST Sat/Sun.

Pharmacy Error Reporting

WithMe Health is committed to the safety of our patients. If you experience an error with your prescription, please notify us by calling 1-866-840-1877.

Providers

Are you a healthcare provider? If so, visit our Provider page for additional information.