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Pharmacy

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Pharmacy

​​All medical and prescription services are subject to a combined annual health deductible and coinsurance maximum based on the tier of coverage, except for mandated preventive services or designated preventive prescriptions.

HDHP Plans: 
Preventive Drug List includes the following items:
  • Selective Serotonin Reuptake Inhibitors
  • Blood Pressure Meters (1 per year with a prescription, check the formulary for brand covered)
  • Peak Flow Meters (1 per year with a prescription, check the formulary for brand covered)
Pharmacy Plan 
Specialty Drugs Only: HDHP Plans: 
Manufacturer copay/financial assistance is a great benefit to help pay for costly Specialty drugs. In the past, manufacturer assistance was applied outside of the plan and the actual cost paid by the member was not accurately applied to their annual health deductible and coinsurance accumulators. This was an unintended benefit due to pharmacy systems not being able to apply the manufacturer's assistance first. 
Members using Specialty drugs through (Briova/UHC) will have the manufacturer's assistance applied up front and only the actual amount a member pays out of pocket will be applied to their annual deductible or coinsurance accumulators.  Member will continue to receive the same financial assistance from the manufacturer; however, that assistance will now be incorporated into the member’s health deductible and coinsurance.

Example:  Specialty drug costs $1,000 per month.  The manufacturer's Assistance is $900 per month.
​Currently

​Member fills prescription through Specialty pharmacy in January.
$1,000 is charged to the member as part of the annual deductible.
Manufacturer assistance is then applied outside of the plan and the member actually pays only $100.

Member refills prescription in February. $1,000 is applied to the remaining deductible then 20% coinsurance.  Member actually pays only $100
​Annual Deductible:
Rx Cost

Remaining Deductible

Rx Cost to deductible

Rx Cost to Coinsurance
​  $1,400
-$1,000

 $  400

-$  400

-$  180

​Copay Card Accumulator Program

​Member fills prescription through Specialty pharmacy in January.  
Member is responsible for $1,000 but has manufacturer assistance of $900.
Manufacturer assistance is applied as part of the plan and the member is responsible for $100.

Member refills prescription in February.
Member continues to pay $100 until the Deductible is met, then 20% coinsurance.
​Annual Deductible: 
Rx Cost after manufacturer assistance

Remaining Deductible

Rx Cost after Assistance

Remaining Deductible

​ $1,400
-$100


$1,300

$100

$1,200


Highlights of Pharmacy Plans
  • Maintenance medications can only be filled for 30 days x 3 fills, then must be filled as 90 days.
  • Specialty medications can only be filled for 30 days through the vendor’s designated Specialty pharmacy (CCP-Southern Scripts, UHC- Optum Specialty Rx (name changed from BriovaRx).
  • 90-day mandatory maintenance medication program at retail or mail order.
  • A large network of participating pharmacies (Publix, Walgreens, Target, CVS, etc.).
  • Restricted generic policy (generics will be dispensed if available unless the doctor indicates “Dispense As Written” (DAW1) due to medical necessity on the prescription. If the drug is not on the Formulary, the doctor will be required to submit a Prior Authorization request detailing the medical necessity for the non-formulary drug. (CDH Plans: Member will pay a higher copay. HDHP Plans: Drugs will not be covered at no cost if generic is on the Preventive Drug list).
  • 30-day Specialty pharmacy home delivery.   
  • Some prescriptions require Step Therapy and/or Prior Authorizations and are shown on the Formulary with an ST or PA.