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Section III - Pharmacy Rx Plan - Catamaran (Formerly Catalyst RX)
Broward County > Benefits > Section III - Pharmacy Rx Plan - Catamaran (Formerly Catalyst RX)

Pharmacy benefits are provided under the County’s self-insured pharmacy plan through Catamaran (formerly Catalyst Rx and Walgreens Health Initiatives, Inc.) The plan includes:

  • An open formulary with three tiers of coverage at very affordable copays
      - Generic Preferred, Brand Preferred and Non-Preferred
  • 90-day mandatory maintenance medication program
  • Restricted generic policy 
  • Large network of participating pharmacies
  • Specialty pharmacy home delivery

YOUR COST AT RETAIL OR MAILORDER
Your prescription copay is based on the type of medication and the quantity purchased.

TYPE

30 DAY SUPPLY*
(AT ANY PARTICIPATING RETAIL PHARMACY)

90 DAY SUPPLY
(AT A LOCAL WALGREENS RETAIL PHARMACY
OR BY MAIL SERVICE)

Generic Preferred

$5

$10

Brand Preferred

$25

$50

Non-Preferred

$40

$80

Specialty Pharmacy

$25 or $40 based on tier

Not available

*Maintenance medication: Two retail fills allowed before mandatory 90-day supply requirement

PREFERRED MEDICATION LIST (PML)

A Preferred Medication List (Formulary) is the list of prescription drugs covered under your plan for a lower copay. It is created, reviewed and updated annually by a team of doctors and pharmacists. Your plan’s Preferred Medication List contains a wide range of preferred generic and preferred brand-name drugs that have been approved by the U.S. Food and Drug Administration (FDA). Your doctor can use this list to choose medications for you while helping you save the most money by utilizing formulary drugs.

MANDATORY 90-DAY MAINTENANCE MEDICATION PROGRAM

Most maintenance medication is subject to a mandatory 90-day supply obtained through either mail or at any participating retail pharmacy. The member pays only two copays for a three-month supply, thus saving the member one copay on each order. Maintenance medications are typically drugs that must be taken for an extended period of time for such conditions as high blood pressure, diabetes, cholesterol, etc. By law, some controlled substances cannot be written for more than 30 days, and as such, can only be purchased for 30 days at a time.

If your doctor begins your treatment plan with only a 30-day prescription, you will only be able to fill it two times at a retail pharmacy. All subsequent refills must be written for a 90-day supply with appropriate refills. The Maintenance Medication program allows you to fill your 90-day prescription at local participating pharmacies or utilize the mail service program. If your doctor feels an extra 30 day trial is needed, submit a written request on a prescription or letterhead to Human Resources-Employee Benefit Services for review and authorization for Catamaran to override the 90 day requirement for one additional month.

Likewise, if your doctor is weaning you off a prescription and you do not need a final 90-day refill, submit a written request on a prescription or letterhead to Human Resources-Employee Benefit Services for review and authorization for Catamaran to override the 90-day requirement. 

If your doctor feels it is medically necessary to write a prescription for 30 days instead of 90-days on an ongoing basis, submit the doctor’s written request to Human Resources-Employee Benefit Services for review and authorization to override the 90-day maintenance medication requirement to the pharmacy vendor. 

Reminder: Ninety day medications can be filled at any participating retail pharmacy.

RESTRICTED GENERIC POLICY

The plan requires substitution of a generic equivalent for brand-name drugs, when available; otherwise a surcharge will be applied. If your doctor believes there is a medical need for you to have the brand name prescription for which there is a generic available, the physician must write “Dispense as Written” on the prescription in order to avoid paying a brand name surcharge as explained in the chart below.

BRAND VERSUS GENERIC MEDICATIONS

A drug’s brand name is the name that appears in advertising. This name is protected by a patent so that only one company can produce it for 17 years. After the patent expires other companies may manufacture a “generic” that’s just like the brand-name drug and that follows FDA rules for safety. A generic’s color or shape may be different, but the active ingredients must be the same. Your formulary lists only FDA-approved generic medications. An example of a generic medication is diazepam, which is the generic equivalent of Valium®.

IMPORTANT: If you wish to explore more cost effective options, ask your doctor if there is a generic equivalent available within the same therapeutic class.  Doing this will result in much greater cost savings to you.

PREFERRED VERSUS NON-PREFERRED MEDICATIONS

A preferred brand name drug, also known as a formulary drug, is a medication that’s been reviewed and approved by a group of doctors and pharmacists within the pharmacy provider. It is chosen for the Preferred Medication List because it’s been proven to be safe, effective and less expensive than another name brand. All other drugs are available at the higher non preferred copay. Note: certain drugs/medications are excluded or have quantity limits under the pharmacy plan.

SPECIALTY PHARMACY MEDICATIONS

The Specialty Pharmacy Program is used for treating complex health conditions and requires special handling for home delivery. Examples are Cystic Fibrosis, Enzyme Deficiency, Growth Hormone Deficiency, Multiple Sclerosis, Rheumatoid Arthritis, and Viral Hepatitis. For more information, members should contact the Specialty Pharmacy.  Specialty medications are not eligible for a 90-day supply and can only be filled for a 30-day supply for one co-pay based on formulary tier. As these medications are so specialized and are very expensive, the first fill of a new specialty prescription will be shipped in two-week increments. If there are no changes to the dosage or drug after the first month, the following months will be filled and shipped as 30-day supplies.

PHARMACY COPAYMENTS:

The following chart will help explain what copayment you would be expected to pay.

YOU WILL PAY
THE FOLLOWING COPAY

$5 GENERIC  PREFERRED
MEDICATION LIST

$25 BRAND
PREFERRED MEDICATION LIST

$40 BRAND
NON-PREFERRED

When a generic is
available ….

You pay $5

When purchasing a brand drug on the Preferred Medication List having "Dispense as Written" (DAW) on the script you pay $25.

If you request a brand drug on the Preferred Medication List without having "DAW" written on the script, you will pay $25 plus the difference between the generic price and the brand price.

When purchasing a brand drug not on the Preferred Medication List having "Dispense as Written" (DAW) on the script you pay $40.

If you request a brand drug not on the Preferred Medication List without having "DAW" written on the script, you will pay $40 plus the difference between the generic price and the brand price.

When a generic is not available ….

Not applicable

When purchasing a brand drug on the Preferred Medication List you pay $25.

When purchasing a brand drug not on the Preferred Medication List you pay $40.

PHARMACY ID CARDS

Upon enrollment in the County’s health program, the pharmacy provider will mail two ID cards and a member packet to the home address as listed in the County’s payroll system. It is important to retain this information for reference. Member ID cards will be issued in the name of the employee; however, enrolled dependents are authorized to use them.  You should keep your ID card with you for verification purposes at participating pharmacies. For additional ID cards, contact pharmacy vendor’s Customer Service at the number shown on your card. Do not discard your card at the end of the plan year as new ID cards will not be issued unless there is a plan or name change.

PHARMACY NETWORK PROVIDERS

Most pharmacy chains are participating providers. You must present your Catamaran pharmacy ID card when you use your benefit at any of the participating national chains.

PRIOR AUTHORIZATION PROGRAM

Certain prescriptions require prior authorization (approval before they will be covered). Types of prior authorizations include, but are not limited to, medications where a set amount is allowed within a set timeframe and an additional amount is requested within the same timeframe, where an age limitation has been reached and/or exceeded or where appropriate utilization must be determined. Catamaran, in its capacity as the pharmacy benefit manager, administers the clinical prior authorization process on behalf of Broward County.

Clinical Prior Authorization (CPA) can be initiated by the pharmacy, the physician, or you or your covered dependents by calling 1-877-665-6609 Monday through Friday, 8 a.m.-8 p.m., Central Standard Time (CST). The pharmacy may call after being prompted by a medication denial with a message stating, “Prior authorization required; call 1-877-665-6609.” The pharmacy may also pass the information on to you and require you to request the prior authorization.

After the initial call is placed, the Clinical Services Representative obtains information and verifies that Broward County participates in a CPA program for the particular drug category. The Clinical Services Representative generates a drug-specific form and faxes it to the prescribing physician. Once the fax form from the physician is received by the Clinical Call Center, a pharmacist reviews the information and approves or denies the request based on established protocols. Determinations may take up to 48 hours from Catamaran’s receipt of the completed form from the prescribing physician, not including weekends and holidays.

If the prior authorization request is approved, the Catamaran’s Clinical Services Representative calls the person who initiated the request and enters an override into the Catamaran claims processing system for a limited period of time. The pharmacy will then process the prescription.

If the prior authorization request is denied, the Catamaran Clinical Call Center pharmacist calls the person who initiated the request and sends a denial letter explaining the reason for denial. The letter will include instructions for appealing the denial. For more information, see the “Appeal Procedures” section.

The categories/medications that require clinical prior authorization may include, but are not limited to: Acne (topical after age 24), ADHD/Narcolepsy (after age 19), Anabolic Steroids (all forms), Anti-Fungals, Atopic Dermatitis, Byetta, Botulinum Toxins, Fentora, Growth Hormones, Lamisil/Sporanox, Penlac, Ranexa. Upon receipt of a prescription falling into a covered category, the pharmacy vendor will contact your doctor’s office and request the documentation needed for Prior Authorization.

MEDICATIONS WITH QUANTITY LIMITS

Some medications have limits on the quantities that will be covered under the County plan. Quantity limits are placed on prescriptions to make sure you receive the medication you need in the quantity considered safe. That is, you get the right amount to take the daily dose recommended by the FDA and medical studies. Some medications with quantity limits include, but are not limited to: Duragesics, Erectile Dysfunction medications, Hypnotics, Migraine Medications, Nasal Inhalers, Proton pump inhibitors, Sedatives.

When you go to the pharmacy for a prescription medication with a quantity limitation, your copayment will only cover the quantity allowed by the plan. You may still purchase the additional quantities, but you will pay the full cost. If your doctor feels there is a medical necessity to override the quantity limit, have them submit their request with medical documentation to Catamaran’s Clinical Prior Authorization department.

HOW TO FILE AN APPEAL ON A DENIED PRESCRIPTION

In the event of an adverse benefit determination by Catamaran, you have the right to appeal the decision by sending a written request to Human Resources-Employee Benefit Services. Your appeal must state:

  • Name of the member
  • Name of the employee if denial was for a dependent
  • Employee ID #
  • The denial letter you received from Catamaran
  • Any additional medical documents, information or comments you think may have a bearing on your appeal.

Send to:

 Benefits Manager
 Employee Benefit Services
 115 S. Andrews Ave., Room 514
 Fort Lauderdale, FL  33301

If the appeal is regarding a denial of a Clinical Prior Authorization (CPA) or other clinical issue, either Catamaran or an independent review organization (IRO) contracted by Catamaran will provide you with the resolution to your appeal. Please note that denials of a CPA due to medical information not being received by Catamaran from your physician will not be considered for the appeal process. Also note that plan design and Preferred Medication List content are not issues that can be appealed.

For denied CPA appeals, Employee Benefits Services will forward the appeal request and medical necessity documentation that you submit from the prescribing physician to Catamaran. Catamaran will either review the appeal internally or forward the appeal request to the IRO for review. The IRO assigns an independent physician to review your appeal based on the issue. The IRO physician will review the appeal and make a recommendation. The IRO submits its recommendation to Catamaran’s Clinical Center, which notifies you by mail of the resolution, with a copy to the Employee Benefits Services. The turnaround time for a CPA appeal is 10 business days from the date the appeal is received by the IRO, excluding holidays and weekends.

If the appeal is regarding a clinical issue such as prospective reviews, quality of care, retrospective reviews or other types of appeal requests that are not classified as a CPA, the appeal follows the same process as above, with a turnaround time of 30 business days from the date the IRO received your information, excluding holidays and weekends.

WEBSITE REGISTRATION

Catamaran provides a secure Web site where you can set up your account and have access to your pharmacy records and other pharmacy related information and tools such as:

  • Access to your pharmacy benefit information
  • Order refills through mail service
  • Medication costs
  • Discover lower cost and generic alternatives for your medications
  • Locate your nearest participating network pharmacy
  • Access and print your medication claims history