Copays
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| Formulary Prescription Drug Benefits at Network Retail Pharmacies and Mail Order | Per Prescription Copays as of 1/1/2022 | |||
|---|---|---|---|---|
| Retail Pharmacy (up to a 34-day supply) or Mail Order Pharmacy (up to a 60-day supply) | ||||
| Prescription Drug Benefits—What You Pay | Platinum+ and Platinum | Gold+ and Silver+ | ||
| Preventive Healthcare Services Drugs | $0 | $0 | ||
| Generic and Some Brand Drugs | $3 | $5 | ||
| Preferred Drugs | $15 | $15 | ||
| Non-Preferred Drugs | $30 | $30 | ||
| Select Specialty and Select Biosimilar Drugs* | Generic | Brand | Generic | Brand |
| $3 | 25% | $5 | 25% | |
| Non-Formulary Prescription Drugs and Supplies | Not covered, unless an exception is approved | |||
| Out-of-Pocket Spending Limit | $1,600 individual; $3,200 family | |||
| * Current pharmacy benefit provider will actively manage and determine drugs in tier. Specialty drugs are only available through the specialty mail order pharmacy or the Atlantic City Health Center. However, effective January 1, 2022, if you take specialty medications as part of your HIV treatment plan, you may be able to receive an exception to use your network retail pharmacy instead. | ||||
Brand name drug with generic available
If you or your healthcare provider insist on a brand name drug when a generic equivalent is available, you must pay the generic copay plus the difference in cost between the brand and generic drug.
Example:
If the generic copay is $10, the brand name drug is $80 and the generic is $50, you will pay $40. $10 copay plus $30 difference in cost.
For questions about your drug benefits, call the number on the back of your medical ID card.
Your network MAY include pharmacies not listed in the link below – call us to find out if a pharmacy you do not find is in your network.
View your network pharmacies here.
Remember: Don't go out of network, you will pay 100% of the cost!
Why we use a "Formulary"
Your health fund is always looking to get you the best deal, while still offering the medicines you need. One challenge is that drug companies can change their prices whenever they want, and drugs sometimes become very expensive.
By using a “formulary” (the list of drugs covered by your plan), we rely less on drug companies. While some generic and brand name drugs are not covered under your plan, other drugs that are just as good — and often have the exact same ingredients — are still available at a much better price.
Make sure your prescriptions are covered
Search for drugs in our new drug formulary lookup
The formulary may change throughout the year. If your prescription is ever affected, we will notify you right away so your doctor can help you find the best medication for you.
Other Information
Formulary Lists
You can get diabetic supplies from any retail pharmacy that’s in the network or by mail order. If you need a new glucometer, get one for FREE:
- Contact One Touch:
- Visit www.OneTouch.orderpoints.com or call (800) 227-8862
- Use order code: 739WDRX01
- Contact FreeStyle (by Abbott):
- Visit www.ChooseFreeStyle.com or call (866) 224-8892
- Use order code: U2L65MBU
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 Brand Name drugs before the prescription is picked up. If you need to take a drug that requires prior authorization, your doctor must call (844) 484-4726.
- 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.” If you are receiving more than what is considered safe (by the U.S. Food and Drug Administration), your health fund will not pay for it.
These programs save you and your health fund money, keep you safe, and prevent abuse and fraud.
We know it is sometimes medically necessary to take a drug even if it is the more expensive option. In these situations, your doctor must get approval by calling (844) 484-4726.
Medications may be added to the Step Therapy and prior authorization lists throughout the year. If your prescription is ever affected by this, we will notify you before the change.
Specialty Drugs
These include drugs used to treat health conditions such as growth hormone deficiency, hepatitis C, immune deficiency, hemophilia, multiple sclerosis and rheumatoid arthritis.
- We work with WellDyne Specialty Pharmacy to get the best service and the best prices. If you need a specialty drug, you MUST get them through this specialty pharmacy. Your doctor MUST first get approval by calling: (800) 641-8475
- We will help you with this transition process. If you are currently taking a Specialty drug, have your doctor call us at (844) 857-5772 to learn how to transition to WellDyne Specialty Pharmacy.
- Because of an exciting new program we are using, you may pay less some months for your Specialty drugs than the listed maximum copay—we will provide details when we contact you.
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, WelldyneRx, at (844) 813-3860.