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| IntroductionAfter you have read the following section concerning
how your Pharmacy PLan works, Click HERE and you’ll be linked to the Partners Rx website where you can find information on virtually any drug on the market. When you type in the name of the drug on the Partners Rx site, you will be informed if the drug is Formulary or Non-Formulary. We cannot stress enough how important
it is for you to understand HOW the Formulary works!
You understanding IS VERY IMPORTANT to your proper
use of your Pharmacy benefit plan and very important to
your finances with your HSA! |  |
| Important, PLEASE READ:Click here to view drugs unique to your Plan that are either EXCLUDED or ADDED to the Partners Rx Formulary. |
| Your Prescription drug benefits include medications available only on the drug list which is called a “formulary.” These drugs are FDA-approved, brand-name and generic medications that have been reviewed and recommended for their quality and effectiveness by Athem’s committee of practicing physicians, clinical pharmacists and other professionals.
To get you the lowest possible costs, Partners Rx has negotiated pricing contracts with the nation’s largest pharmacies. Obviously, some drugs cost more than others. Although some pharmacies NOT on the Partners Rx list will honor your Partners Rx discounts, when you buy in the Partners Rx “network” of pharmacies, you save the most. You also save the most when you purchase generic drugs. Thus, Partners Rx has set up a system to catagorize all drugs in five (5) tiers. Tiers 0, 1 & 2 offer you the lowest costs while Tiers 3 & 4 generally cost more and DO NOT even qualify for reimbursement. Here’s an explanation of how the Formular Tiers are set up: |
| Tier 0 - "Over-the-Counter" (OTC) DrugsThere are only THREE Tier 0 Drugs, Prilosec, Alavert and Claritin D. Even though these three drugs are sold OTC, in order to get your expenses qualified under the plan, you must first have a prescription from your doctor for the particular drug. Then, as with any other phramacy processed prescription, you can pay for the OTC drug by presenting the pharmacist with your Member ID card for bill processing through the pharmacy’s electronic payment system. |
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| PLAN COVERAGE: Under your plan, 100% of the cost will either count toward your deductible, or it will be reimbursed by the Plan AFTER you have met your deductible.
Prilosec 20mg OTC is much less expensive drug than the prescription drugs: Protonix, Nexium, Prevacid, or Aciphex
Claritin 10mg, Claritin-D 10-240mg, Alavert 10mg, and Alavert Allergy Sinus are much less expensive OTC drugs than the presecription drugs: Allegra 180 mg, Allegra D 12 hour, Zyrtec 10mg and Zyrtec D 5-120mg |
| Tier 1 - Generic DrugsLowest cost. A generic drug is required by the FDA to have the same active ingredients as its brand-name counterpart, but it is normally available ONLY AFTER the patent protection expires on a brand-name drug. Although a generic drug may look different, it works the same as its brandname counterpart. You can save money by using generic medications.
PLAN COVERAGE: Under your plan, 100% of the drug cost will either count toward your deductible, or it will be reimbursed by the Plan AFTER you have met your deductible. |
| Tier 2 - Brand Name Drugs, Generics Not AvailableBrand Name Drugs are usually available from only one manufacturer and their formula may be protected by a patent. The drugs in Tier 2 are Brand name drugs that have no generic drug substitute.
PLAN COVERAGE: Since there is no generic substitute, 100% of the cost of the Tier 2 drugs will either count toward your deductible, or it will be reimbursed by the Plan AFTER you have met your deductible. |  |
| Tier 3 - Brand Name Drugs, Non-Furmulary, Generic Drugs AvailableThe drugs in Tier 3 are called “Non-Formulary” because Partners Rx has determined that there are less costly generic drugs that can be substituted for these brand-name drugs. Sometimes, the equivalent generic drugs are even sold “over-the-counter” without a prescription.
PLAN COVERAGE: If you choose to buy the Brand Name Drug and not the generic drug, ONLY the cost of the generic drug will count toward your deductible or be reimbursed by the Plan after your deductible is met. In other words, you must pay the cost difference between the Brand Name drug and the generic drug. You may reimburse yourself from your H S A for the additional cost, but your personal reimbursement will NOT count toward your deductible. In summary, your plan ONLY covers the cost of the generic equivalent drug.
Example: Herbert gets a prescription from his doctor for Nexium (a Tier 3 Brand drug) costing $100. Under the Plan he would have to pay the difference between the cost of Nexium (Brand Name Drug) at $100 and the equivalent OTC generic prescription at $10. Thus, his personal, non-plan cost would be $90. However, Herbert knows that Prilosec is just as effective, is far less costly, and is available as a Tier 0 “Over The Counter” (OTC) 20mg tablet. The Prilosec tablet only cost .70 cents per pill versus $5.09 per pill for Nexium! Herbert has his doctor write a prescription for Prilosec instead of Nexium. He then selects Prilosec from the OTC area of the store and takes the Prilosec to the pharmacist to process the transaction through the pharmacy’s electronic payments system. Herbert’s plan pays 100% of the Prilosec and saves Herbert $100. AND, the cost of Prilosec will count towards Herbert’s deductible. If he had bought Nexium and paid an additional $90 dollars, he would have drained his H S A of the $90 and only $10 the cost of the equivalent generic would have been counted towards his deductible. Smart guy, that Herbert! |
| Tier 4 - Unique of Injective Brand Name Drugs, Non-FormularyA brand-name drug that is usually available from only one manufacturer and may have patent protection; however, there are lower cost generic drugs available and/or other brand drugs from Tiers 0, 1 or 2 that are less costly.
Only the cost of the generic drug will count toward your deductible and be reimbursed by the Plan after your deductible is met. You must pay the cost difference between the Brand Name Drug and the generic drug. You may reimburse yourself from your H S A, but this reimbursement will NOT count toward your deductible. In summary, your plan ONLY covers the cost of the generic equivalent drug.
Drugs NOT on the Formulary. Cost is not covered by the Plan. Expenses do not count toward deductible and expenses are NOT reimbursed by the Plan even after the deductible is met.
Because the medications on the drug list are subject to periodic review, please ask your doctor about the most current drug list additions and deletions, or click here and you’ll be linked to the Partners Rx website. If you don’t see your medication on the drug list, ask your physician or pharmacist if there is an appropriate alternative medication |
| SPECIAL CONSIDERATIONS:There are certain drugs that require special considerations. The following are the “keys” to determine if the drug you are looking for needs these special considerations:
PA = Prior Authorization Required
Prior authorization is the process of obtaining approval of benefits before certain prescriptions may be filled. Prior approval must be obtained from your Case Manager, Advocare.
QL = Quantity Limits
Certain prescription drugs have specific quantity limits per prescription or per month. When you submit your Member ID, the Pharmacist will automatically know if there is a quantity limit on your prescription drug.
ST = Step Therapy Required
You may need to use one medication before benefits for the use of another medication can be authorized. Please note: Foradil and Serevent are safety edits that prevent duplication of therapy.
DO = Dose Optimization Required
Normally involves the conversion from twice daily dosing to a once-daily dosing schedule.
For Kentucky Residents Only:
In selecting medications for the prescription drug list, the therapeutic efficacy and cost effectiveness are addressed for each category. All therapeutic categories are represented on the drug list by at least one medication. When a closed drug list is in effect, only medications that are included on the drug list are a covered service. In certain clinical situations, a member may require use of a medication not included on the drug list (Tier 3 ). Partners Rx has criteria that permits a member to obtain a Tier 3 medication in a closed drug list plan. If specific criteria are met, a member can receive a Tier 3 drug at 100% application toward deductible and for 100% reimbursement after meeting the deductible. The criteria preserves the clinical integrity of the drug list and provides a process by which deviations from the drug list may be allowed. A process is in place to request medications be added to the drug list for any medications that do not meet the criteria. |
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