|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|
|Select Specialty and Select Biosimilar Drugs*||Generic||Brand||Generic||Brand|
|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.|
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.
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!
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.
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.
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:
These are programs your doctor MUST use:
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.
These include drugs used to treat health conditions such as growth hormone deficiency, hepatitis C, immune deficiency, hemophilia, multiple sclerosis and rheumatoid arthritis.
Mail order pharmacy program: