What are my prescription copays or coinsurance?

The amount you pay for your medication(s), can be located in your Plan's Summary of Benefits.

What is an OTC or over-the-counter medication?

Any medication that may be purchased without a prescription. Over-the-counter medications are also known as OTC medications. OTC medications are excluded from coverage under Medicare Part D.

What is a generic equivalent?

A medication that contains identical amounts of the same active drug ingredient in the same dosage form and route of administration that is expected to have the same clinical effects and safety profile as another product as designated by the United States Federal Food and Drug Administration (FDA).

Are generic drugs safe and effective?

Yes, according to the Federal Food and Drug Administration (FDA) generic drugs are safe and effective. Generic medications must meet the same standards for purity, strength, and quality as brand name drugs. They must be approved by the FDA before they can be sold to consumers. Generics may look different from the brand name medication in color, shape, or size as required by the Federal Food and Drug Administration (FDA).

What is the prior authorization medication list?

To promote the most appropriate utilization, certain medications require an approval of a prior authorization by our Pharmacy Department. Upon enrollment or upon request, the member will receive a list of prior authorized prescription drugs. These medications are also identified on the Formulary with a (PA) after the drug name. Prior authorization criteria is established by our Pharmacy and Therapeutics Committee with input from plan physicians and consideration of the current medical literature. If a medication is required that is not routinely covered, the provider may present medical evidence to obtain an individual patient exception by submitting an exception request for review.

What is a Step Therapy medication list?

Certain prescription drugs may be subject to Step Therapy. We have implemented Step Therapy programs in several drug classes where lower cost brand name drugs are available and are similarly effective. Step Therapy means a member would need to try the drug(s) listed as first line, before a second line drug would be covered. If there is medical documentation and/or prescription history to indicate that the first line drug was previously tried, or that you are unable to attempt a trial of the first line drug for medical reasons, then your physician may submit an exception request for review. If approved, the authorization will allow you to move directly to the second line of drugs in that drug class.

What can I do if my prescription drug requires a Prior Authorization, or is not covered?

As a member of Senior Preferred, you may initiate an exception request process. For your convenience, we have prepared a form that you may complete and fax or mail to us. To complete the Drug exception request click here.

What is a mail service pharmacy?

A mail service pharmacy delivers medicines to your home through the mail. By using a mail service pharmacy you can get up to a 90-day supply of medication, often at a lower copayment. Mail service pharmacies deliver medicines in a confidential package. Many people prefer the convenience of this type of service. Senior Preferred members are not required to use a mail service pharmacy. However, if you are interested in using one, please call Customer Service. More details may be found here.

How do I request reimbursement for a prescription I paid for myself?

When purchasing prescription medications, you are encouraged to use your Pharmacy Prescription Card. If for some reason you are unable to utilize your pharmacy card, and are required by the pharmacy to pay for the medications, you may submit your itemized pharmacy receipt to us. Prescription medications purchased from a pharmacy will be reimbursed through our Pharmacy Benefits Management (PBM) at our current discount contracted rates. Any difference between the discount contracted rate and what the provider has billed will be your responsibility.

 

 

This webpage was updated on October 1, 2017.