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Coventry One SC Prescription Guide

Prescription Drug Program

WellPath’s goals for our prescription drug benefit are to support the quality or effectiveness of treatment and to provide a comprehensive, affordable pharmacy benefit. Designed to provide maximum geographic coverage, the pharmacy network consists of more than 62,000 pharmacies in the United States, Puerto Rico, and the Virgin Islands. The network includes national chains and independent drug stores. You can view a directory of participating pharmacies using the Pharmacy Locator tool on our website, www.wellpathonline.com.

WellPath has contracted with Medco as our pharmacy benefit administrator to offer the prescription drug program. This program offers:

  • Coverage for certain over-the-counter (OTC) drugs. WellPath members can obtain Zaditor OTC, Zyrtec OTC, Alaway, Prilosec OTC, Alavert, Miralax, Claritin OTC, Plan B, and Next Choice for a generic copay when a prescription from a physician is submitted.
  • Affordable copayments that give you a choice of covered drugs.
  • The convenience of mail order.
  • The ability to view prescription history, search drug information, locate a retail pharmacy, view mail order prescription status, download refill reminders, access My Rx Choices prescription savings program, and transfer retail prescription to mail order, all online.
  • A single sign-on link to the Medco website for password-protected personal services. When you login to WellPath’s My Online ServicesSM and have previously registered on the Medco site, you will be able to access your Medco information without logging in again.

Important points to remember when accessing your pharmacy benefits

  • You must use your ID card or have your membership information available to fill a prescription. You may only file a claim for reimbursement for a prescription after it was purchased if it is a true emergency. Exceptions may be made if you have not yet received your ID card but need to fill a prescription.
  • If PA is listed next to a drug, prior authorization is required.
  • Even if your prescription drug has been approved by a previous carrier, it may still need to be prior authorized by WellPath.
  • Retail prescriptions must be filled at a participating pharmacy or a nonparticipating pharmacy if it is an out-of-area emergency or urgent care situation. You pay the appropriate copayment or the cost of the medication if it is less than the copayment.
  • If you take specific maintenance medications on a regular basis, you may be eligible to get your prescriptions filled through the mail order program. The mail order benefit allows up to a 90-day supply to be delivered directly to your home. WellPath does not cover certain drugs such as controlled substances through the mail order program. To find out about mail order coverage, please call Member Services.

Our Prescription Drug List (Formulary)

Members enrolled in a plan with a prescription drug benefit have access to medications that are on WellPath’s Prescription Drug List, also known as a Formulary. A Prescription Drug List is a list of approved medications covered by WellPath. The Prescription Drug List includes a list of both brand name and generic medications. You also have access at a higher copayment to medically necessary prescription drugs not listed on the Prescription Drug List. The 2010 Prescription Drug List is located on our website at www.wellpathonline.com. A list of drugs with quantity limits, drugs requiring preauthorization, self-administered injectable drugs, drugs with mail order exclusions, and prescription drug quantity limits are on the following pages.

Why Use a Formulary

Formularies have two purposes:
•Ensure that the drugs offered are of the highest quality and efficacy
•Reduce prescription costs
Lower prescription costs enable us to keep our premiums reasonable while offering a high level of benefits. A committee of pharmacists and doctors compares each drug’s safety, side effects, and effectiveness. Based on research and discussion, this committee decides which ones are best for the Formulary.

Prescription Drug Program

Our Prescription Drug List (Formulary)

Members enrolled in a plan with a prescription drug benefit have access to medications that are on WellPath’s Prescription Drug List, also known as a Formulary. A Prescription Drug List is a list of approved medications covered by WellPath. The Prescription Drug List includes a list of both brand name and generic medications. You also have access at a higher copayment to medically necessary prescription drugs not listed on the Prescription Drug List. The 2010 Prescription Drug List is located on our website at www.wellpathonline.com. A list of drugs with quantity limits, drugs requiring preauthorization, self-administered injectable drugs, drugs with mail order exclusions, and prescription drug quantity limits are on the following pages.

Why Use a Formulary

Formularies have two purposes:

  • Ensure that the drugs offered are of the highest quality and efficacy
  • Reduce prescription costs

Lower prescription costs enable us to keep our premiums reasonable while offering a high level of benefits. A committee of pharmacists and doctors compares each drug’s safety, side effects, and effectiveness. Based on research and discussion, this committee decides which ones are best for the Formulary.

Making It Work for You

Have your physician choose a medication from the Formulary. That will eliminate potential problems.

Read these guidelines carefully.

Before your doctor prescribes a medication, ask if the medication is on the WellPath Formulary. Try to have a copy of the Formulary with you when you go to the doctor. Ask your doctor to prescribe a medication from the Formulary.

Prior Authorization*

If PA is listed next to a drug on the Prescription Drug List, prior authorization is required. These medications include those that are 1) not suggested for first-line therapy, 2) may require special tests before starting them, or 3) have very limited approval for use. Your physician must receive prior authorization from WellPath before you fill the prescription. If prior authorization is not received, your medication may not be covered.

Quantity Limits

Some medications on the Prescription Drug List have restrictions on the quantity that WellPath will cover. Examples of these drugs include those that are FDA-approved to be taken once daily and instances where the total dose of a medication is available in one pill. For example, several inhalers for asthma can cause severe side effects if overused. The quantity limit will alert you to seek medical advice rather than another inhaler. This way you can be sure you are not taking too much of the medicine, which could endanger your health. Prior authorization may be required if the dosage of the medication being prescribed varies from the FDA and manufacturer’s recommended dose.

Prescription Drug Program

Generic Drugs*

Our benefits cover the generic drug when FDA-approved generics are available. The active ingredients in generic medications are the same as in brand-name products. The FDA regulates the production of generic drugs to assure that they provide the same benefit to patients as the original drug.

If you choose to buy a brand-name medicine when a generic is available, you will pay the brand-name copayment plus an ancillary charge. This ancillary charge equals the difference in price between the brand-name drug and its generic equivalent. However, you or your doctor may choose to have a brand-name drug even when a generic is available.

Mail Order Advantage*

You may have a mail order pharmacy benefit which offers you the convenience of obtaining up to a three-month supply of certain maintenance drugs. Copayments remain the same for drugs purchased through the mail order program. Not all drugs are available through mail order.

To use the mail order pharmacy:

• Confirm that the drug is available through your mail order benefit by calling our Member Services staff or using our website.

  • Confirm with your doctor that you tolerate the medication, and that it is working well for you.
  • Request a mail order prescription from your doctor. (The prescription should be for up to a 90-day supply.)
  • Complete the brief medication history on the mail order envelope. (The history is required for your first order only.)
  • Mail the prescription(s) and applicable copay(s) in the mail order envelope to Medco. There is no need to send your ID card.
  • You can also order prescription refills online with Medco.com. You should expect delivery within two weeks, although many orders will arrive sooner. Medicines requiring refrigeration will be specially packed and shipped to arrive so they remain potent at no additional cost to you.

Specialty Medications

SP indicates specialty medications. Some plans direct distribution of specialty medications through a participating specialty pharmacy and limit quantities to a 31 days supply. Please call the Member Service number on your ID card for a referral to a participating specialty pharmacy or with questions regarding your pharmacy benefit.

Making It Work for You

Have your physician choose a medication from the Formulary. That will eliminate potential problems.
Read these guidelines carefully.
Before your doctor prescribes a medication, ask if the medication is on the WellPath Formulary. Try to have a copy of the Formulary with you when you go to the doctor. Ask your doctor to prescribe a medication from the Formulary.

Prior Authorization*

If PA is listed next to a drug on the Prescription Drug List, prior authorization is required. These medications include those that are

1) not suggested for first-line therapy,

2) may require special tests before starting them, or

3) have very limited approval for use. Your physician must receive prior authorization from WellPath before you fill the prescription. If prior authorization is not received, your medication may not be covered.

Quantity Limits

Some medications on the Prescription Drug List have restrictions on the quantity that WellPath will cover. Examples of these drugs include those that are FDA-approved to be taken once daily and instances where the total dose of a medication is available in one pill. For example, several inhalers for asthma can cause severe side effects if overused. The quantity limit will alert you to seek medical advice rather than another inhaler. This way you can be sure you are not taking too much of the medicine, which could endanger your health. Prior authorization may be required if the dosage of the medication being prescribed varies from the FDA and manufacturer’s recommended dose.

Prescription Drug Program

Generic Drugs*
Our benefits cover the generic drug when FDA-approved generics are available. The active ingredients in generic medications are the same as in brand-name products. The FDA regulates the production of generic drugs to assure that they provide the same benefit to patients as the original drug.
If you choose to buy a brand-name medicine when a generic is available, you will pay the brand-name copayment plus an ancillary charge. This ancillary charge equals the difference in price between the brand-name drug and its generic equivalent. However, you or your doctor may choose to have a brand-name drug even when a generic is available.
Mail Order Advantage*
You may have a mail order pharmacy benefit which offers you the convenience of obtaining up to a three-month supply of certain maintenance drugs. Copayments remain the same for drugs purchased through the mail order program. Not all drugs are available through mail order.
To use the mail order pharmacy:
• Confirm that the drug is available through your mail order benefit by calling our Member Services staff or
using our website.
•Confirm with your doctor that you tolerate the medication, and that it is working well for you.
•Request a mail order prescription from your doctor. (The prescription should be for up to a 90-day supply.)
•Complete the brief medication history on the mail order envelope. (The history is required for your first order only.)
•Mail the prescription(s) and applicable copay(s) in the mail order envelope to Medco. There is no need to send your ID card.
•You can also order prescription refills online with Medco.com. You should expect delivery within two weeks, although many orders will arrive sooner. Medicines requiring refrigeration will be specially packed and shipped to arrive so they remain potent at no additional cost to you.

Specialty Medications

SP indicates specialty medications. Some plans direct distribution of specialty medications through a participating specialty pharmacy and limit quantities to a 31 days supply. Please call the Member Service number on your ID card for a referral to a participating specialty pharmacy or with questions regarding your pharmacy benefit. Online Drug List Our online Formulary will provide you with important information such as generic and preferred drug alternatives, quantity limits, or prior authorization requirements. You also can access the mail order program. To use the online formulary, visit the “Members” section of www.wellpathonline.com and click on the link for Prescription Formulary on the right side of the page.

Standard Prior Authorization Drugs

Some drugs require prior approval (preauthorization) by WellPath before the prescription will be filled at the pharma-cy. Your doctor will coordinate this approval for you. If the prescription is approved, WellPath will cover the cost. You will be responsible for the copayment. If the request is not approved, it does not mean your doctor cannot prescribe the medicine for you. It means that you are responsible for paying the prescription in full. Self-administered injectable agents also require prior authorization and can be found on a separate list.

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