CopaGOS
ENCONTRAR UNA FARMACIA
| Beneficios de medicamentos recetados del formulario en farmacias minoristas dentro de la red y en pedidos por correo postal Recuerde bajo la Clase II, este beneficio está limitado a medicamentos y suministros de atención médica preventiva. |
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|---|---|---|---|
| Beneficios de medicamentos recetados - Lo que usted pagará (por receta médica) | Farmacia minorista hasta un suministro de 34 días | Farmacia de pedidos por correo postal hasta un suministro de 60 días | |
| Medicamentos para servicios de atención médica preventiva | $0 | ||
| Medicamentos genéricos y algunos de marca | $1 | ||
| Medicamentos de preferencia | $15 | ||
| Medicamentos que no sean de preferencia | $30 | ||
| Medicamentos especializados selectos y biosimilares selectos* | No cubiertos | Genéricos | De marca |
| $1 | 25% | ||
| Medicamentos y suministros recetados que no se encuentran en el formulario | No cubiertos, a menos que se apruebe una excepción | ||
| El proveedor de beneficios farmacéuticos actual administrará y determinará activamente los medicamentos en el nivel. Los medicamentos especializados solo están disponibles a través de la farmacia especializada de pedidos por correo postal. Sin embargo, con vigencia desde el 1 de enero de 2022, si toma medicamentos especializados como parte de su plan de tratamiento del VIH, puede recibir una excepción para usar su farmacia minorista dentro de la red en vez de la farmacia especializada. | |||
Medicamento de marca con genérico disponible
Si usted o su proveedor de atención médica insisten en un medicamento de marca cuando un equivalente genérico está disponible, usted tiene que pagar el copago genérico más la diferencia en el costo entre la marca y el medicamento genérico.
Ejemplo:
Si el copago genérico es de $10, el medicamento de marca es de $80 y el genérico es de $50, usted pagará $40. $10 de copago más $30 de diferencia en el costo.
Para preguntas sobre sus beneficios de medicamentos, llame al: (844) 813-3860.
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En la red |
Fuera de la red |
| CVS CVS/Longs United Drug Albertsons Vons/Pavilion Winn Dixie Costco Kmart Ralph's Pathmark/Waldbaums Randalls Martins/Giant/Stop & Shop Safeway Kroger/Fred Meyer/Fry's/King Soopers Shoprite Supervalu Tom Thumb |
Walgreens Duane Reade Brooks/Eckerd USA Drugs Wal-Mart Ciertas farmacias locales independientes |
Recuerde: No salga de la red, ¡pagará el 100% del costo!
OTRA INFORMACIÓN
LISTAS DEL FORMULARIO DE MEDICAMENTOS
Diabetic Supplies
You can get a free glucometer once every 12 months through Hospitality Rx. The manufacturers provide one free glucometer every 36 months. Please note, manufacturer program details like glucometer mode, order code, and other details may change from time to time.
You can no longer get a free OneTouch glucometer from LifeScan. Instead, effective September 1, 2025, you can get a free glucometer from True Metrix.
- Available once every 12 months
- To order, call (866) 788-9618
- Or, take your glucometer prescription to a network pharmacy. You’ll need the following information:
- BIN: 018844
- PCN: 3F
- Group #: FVTRUEPORT50
- ID #: TRPT5023493
Contact FreeStyle (by Abbott):
- Visit www.ChooseFreeStyle.com or call (800) 680-6850
- Use order code: RAFITLWP
- Your meter will be sent to the address you provide during the ordering process.
- Call Welldyne Rx at (866) 240-2204 to get prior authorization for a new glucometer (the 12-month limit still applies).
- You’ll need a prescription for the glucometer then go to your in-network pharmacy to get your free glucometer.
Programs
These are programs your doctor MUST use:
- Prior Authorization. Your doctor must request approval for all Specialty and Biosimilar drugs and some Preferred and Non-Preferred drugs before the prescription is picked up.
- Step Therapy. Before using some drugs that are very expensive, you and your doctor must try less expensive drugs that are proven to work just as well—sometimes they even have the same ingredients.
- Quantity Limit Program. This is sometimes called “dispensing limits.”There are certain prescription drugs that many providers prescribe at higher dosages than the FDA considers to be safe.
If you need to take a drug that requires prior authorization, step therapy or have Quantity limit, your doctor must call (844) 813-3860 to obtain the approval.
Specialty Drug
You must use the specialty pharmacy for all specialty prescription drugs, which treat chronic or complex conditions like multiple sclerosis (MS) or Hepatitis C. These medications often require special handling, administration, or monitoring. The specialty pharmacy provides expert support, ensures timely refills, and answers questions about your treatment.
If you need a specialty drug, have your doctor send a prescription to one of these specialty pharmacies below and obtain a prior authorization by calling (844) 813-3860.
Healthdyne Specialty Pharmacy
- Phone: (800) 373-1879
- Fax: (800) 530-8589
- E-prescribe: Healthdyne Specialty Pharmacy
UNITE HERE HEALTH Pharmacy
- Electronically: We are listed as the “UNITE HERE HEALTH Pharmacy.” Our address is 1801 Atlantic Ave 3rd Floor, Atlantic City NJ 08401. You can locate us in the system using the ID number- “3148524”
- Phone: (609) 441-7190. Dial 1,1,0 to reach the pharmacist.
- Voicemail: Call (609) 441-7190. Dial 1,1,1 for the voice mailbox.
- Fax: (609) 441-7196.
Mail Order
Mail order pharmacy program:
- Your plan will send medicine straight to your mailbox and it costs less!
- To enroll, call our Mail Order Pharmacy partner, Healthdyne, at (888) 479-2000.