Prescription drug coverage helps you pay the cost of prescribed medications. A Pharmacy Benefit Manager (PBM) manages your prescription drug coverage, which consists of both a retail pharmacy component and a mail order pharmacy component. Benefits are provided for the payment of the prescription charge, less the applicable Co-payment for each separate prescription order or refill.
Almost all prescription drugs are dispensed under two names: the generic name and the brand name. A generic drug is chemically equivalent to a brand drug for which the patent has expired. By law, both generic and brand name medications must meet the same standards for safety, purity, and effectiveness.
Generic medications help to control the cost of health care while providing quality medications – and can be a significant source of savings for you and the Plan. When you receive a brand name medication, you generally pay more because they are more expensive. Your Physician or pharmacist can assist you in substituting generic medications when appropriate. Generic drugs have a lower Co-payment than brand name drugs. For greater cost-savings, always request that your doctor prescribe a generic drug.
If your doctor has not indicated “Dispense As Written” or DAW, your prescription automatically will be filled with a generic drug.
For short-term prescription needs, you can receive up to a 30-day supply of your covered medication for one retail Co-payment. Filling your prescriptions at retail is most appropriate for your short-term prescription needs. For example, if you need an antibiotic to treat an infection, you can go to one of the many pharmacies that participate in the network. Retail pharmacy is also appropriate for situations in which your physician has not established the suitable drugs, strengths, and dosages for ongoing needs.
The Plan provides a national network of participating retail pharmacies. When you purchase covered prescription drugs from a participating retail pharmacy, simply present your prescription order and your ID card to the pharmacy and pay your retail Co-payment. You do not have to submit any paper claims to the PBM when you use a participating retail pharmacy.
When you purchase covered prescription drugs from a non-participating retail pharmacy, you must pay the full price (100%) of the prescription and obtain a prescription receipt that you can submit to the PBM for reimbursement. You will be reimbursed 75% of the Allowed Amount, after deducting the applicable retail Co-payment. You will be responsible for the difference in cost between the amount charged and the Allowed Amount, plus 25% of the Allowed Amount after deducting your applicable retail Co-payment.
If prescription drugs must be purchased from a non-participating pharmacy because you are away from home or due to an emergency, you will still be required to pay the full charge and file the claim for reimbursement. However, you will be reimbursed at 100% of the Allowed Amount for the generic or brand name drug as applicable, after your appropriate Co-payment has been deducted.
Claims for prescription drugs purchased at a non-participating retail pharmacy are available through the PBM and must be submitted within one year of the date dispensed to be eligible for coverage.
Additional information on Prescription Drug Coverage can be found by clicking on any of the tabs above.