8.4 MAIL ORDER PHARMACY PROGRAM
If you need to take maintenance medications on an ongoing basis, you may obtain up to a 90-day supply through the Preferred Participating Mail Order Pharmacy program for direct delivery to your home. Maintenance medications are Drugs prescribed for more than 34 days or taken on a regular or long-term basis. Pre-addressed prescription order forms and envelopes are available from the Trust Customer Service Office, the Administrative Office or the pharmacy benefit manager’s website; please refer to the Quick Reference Table in the front of this booklet.
How to Use the Mail Order Pharmacy Program
Ask your doctor to prescribe maintenance medications for up to a 90-day supply, plus refills. Complete the prescription order form and mail it with your prescription to the mail order program using the special preaddressed envelope. For the protection of each Participant, a “patient health profile” questionnaire must be completed and mailed with the first order. The Mail Order Pharmacy Program will use this health history when reviewing your prescriptions for safety and appropriateness. The Mail Order Pharmacy Program will process your order and send your medications to your home via the U.S. postal service. A new order form and envelope will be returned to you with each prescription delivery.
If you need a prescription immediately, ask your Physician for 2 prescriptions. The first prescription should be for up to a 34-day supply and should be taken to a retail participating pharmacy to be filled. The second prescription should be sent to the Mail Order Pharmacy Program in the envelope provided for that purpose.
When your prescription is filled you will receive a notice showing the number of times it may be refilled. It will also show your prescription number. In addition, there will be a pre-addressed reply envelope enclosed. Simply fill out the information on the reverse side of the reply envelope, enclose the refill notice, seal, stamp and mail. Your prescription will be refilled and mailed back to you.
PRESCRIPTION DRUG COPAYMENTS
|Participating Retail Pharmacy*
|Preferred Participating Mail Order Pharmacy||Non-Participating Pharmacy**|
|Generic Drugs||Participant copayment is 20% of the total cost of the Drug.||Participant copayment is the lesser of 20% of the cost of the drug or $20 for each prescription.||No Reimbursement|
|Preferred Brandname Drugs*
Reimbursement Limitations apply, see below*
|Participant copayment is 35% of the total cost of the Drug.||Participant copayment is the lesser of 35% of the cost of the drug or $50 for each prescription.||No Reimbursement|
|Non-Preferred Brand-name Drugs*
Reimbursement Limitations apply, see below*
|Participant copayment is 50% of the total cost of the Drug.||Participant copayment is the lesser of 50% of the cost of the drug or $100 for each prescription.||No Reimbursement|
Must be filled by participating Specialty Drug mail order facility
|Not applicable.||Participant co-payment is $100 for each Specialty prescription. 30 day supply.||No reimbursement|
If filled through a participating retail pharmacy, the Plan also covers medications and supplements that are designated as “preventive care” under Health Care Reform and which the Plan is required by law to provide. For a list of the covered medications and supplements, see www.hhs.gov/healthcare/prevention. These items are covered at 100% in-network, but you must have a prescription from your doctor (even for the over-the-counter items). Also, not all items are covered for everybody – for example, there are age restrictions, and some items are limited to generic only. Contact the Pharmaceutical Provider for more information.
If you or your Physician request that your prescription be filled with a brand-name Drug when a generic equivalent is available, you will be responsible for paying the full difference in price between the generic and brand-name Drug in addition to your brand-name Prescription Drug copayment. The generic price is established by the Plan’s Pharmaceutical Provider.
**OUT OF NETWORK PRESCRIPTIONS:
If no network pharmacy is located in the area, the co-payment is 50% of the Drug cost per each prescription filled out-of-network.
Specialty medications are generally used in treating unique disease conditions and are typically injectable or that otherwise require special handling considerations. Members that require these specialty medications may receive express delivery to their home or office from the Pharmacy Program Manager’s Mail Order facility and also receive clinical support by pharmacists and other educational material to help maximize treatment success. A list of examples of specialty medications can be obtained by visiting the web site. Specialty medications have a minimum copay of $100 for each 30-day prescription, and a 90-day prescription (with a copay of up to $300) may only be obtained if the participant or beneficiary has been prescribed that specialty medication continuously for at least six months.