Copays
| 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.
For questions about your drug benefits, call: (844) 813-3860.
Find a pharmacy
|
In Network |
Out of Network |
| View your list of network pharmacies | Wal-Mart Sam's Club Certain independent local pharmacies |
Remember: Don't go out of network, you will pay 100% of the costs!
Other Information
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.
For OneTouch (by LifeScan), take your glucometer prescription to a network pharmacy and:
- Give them the below information:
- BIN: 601341
- RxPCN: OHS
- Group ID#: OH6504161
- ID#: NOCHARGEMETR
- Or show this flyer.
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.
If you need a glucometer sooner than the manufacturer allows:
- Call Hospitality Rx at (844) 484-4726 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 the specialty pharmacy 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
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.