Copays
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| Formulary Prescription Drug Benefits at Network Retail Pharmacies and Mail Order. | |||
|---|---|---|---|
| Prescription Drug Benefits—What You Pay (per prescription) | Retail Pharmacy up to a 34-day supply | Mail Order Pharmacy up to a 60-day supply | |
| Smoking Cessation Drugs and Supplies (including prescription generic over-the-counter products, generic products, and certain brand products) | $0 | ||
| Covered Immunizations | $0 | ||
| Generic and Some Brand Drugs | $3 | ||
| Preferred Drugs | $12 | ||
| Non-Preferred Drugs | $27 | ||
| Non-Formulary Prescription Drugs and Supplies | Not covered, unless an exception is approved | ||
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: (866) 686-0003
|
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
Formulary Lists
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.
Contact OneTouch (by LifeScan):
- Visit www.OneTouch.orderpoints.com or call (800) 668-7148
- Use order code: 573EXP333
- Take your voucher and glucometer prescription to a network pharmacy.
Contact FreeStyle (by Abbott):
- Visit www.ChooseFreeStyle.com or call (866) 224-8892
- 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.
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 (877) 266-9991.
- 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. Coverage for these prescription drugs will be limited to a 30-day supply.
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 (877) 266-9991.
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.