The following section outlines information
for members who have SelectHealth
pharmacy benefits.
For more information, call Member
Services at
800-538-5038
, or visit
selecthealth.org
. You can also log
in to
My Health
to access useful
pharmacy tools.
PARTICIPATING PHARMACIES
To get the most from your pharmacy
benefits, use a participating pharmacy
and present your ID Card when you fill
a prescription.
PRESCRIPTION DRUG LIST
SelectHealth plans that offer drug
coverage use a tiered Prescription
Drug List of brand-name and generic
drugs. An expert panel of doctors and
pharmacists (called the Pharmacy and
Therapeutics Committee) selects drugs
for this list based on safety, quality, and
cost-effectiveness. The list may change
periodically because of new drugs, new
therapies, or other factors. The main
difference between the tiers is the amount
you pay. Using Tier 1 drugs, for example,
will cost you less.
GENERIC DRUGS
You can save money by using generic
drugs. Generic drugs contain the same
active ingredients as their brand-name
counterparts. The U.S. Food and Drug
Administration regulates generic drugs just
like brand-name drugs.
A generic drug will usually be substituted,
unless a doctor states on the prescription
that the brand-name drug must be used
for medical reasons. Some plans require
that generic drugs be used and do not
cover brand-name drugs when generics are
available. If you or your doctor requests
a brand-name drug when a generic is
available, you will often pay a higher
copay/coinsurance plus the difference in
cost between the generic drug and brand-
name drug. In some cases, you will need
to pay for the drug in full.
GENERICSAMPLE®
Our GenericSample program eliminates
your copay/coinsurance for the first fill
of select generic prescriptions. The fees
are waived automatically when you pick
up your prescription. GenericSample
is available only through participating
pharmacies. It is not available under the
90-day maintenance drug benefit or on
HealthSave
SM
plans.
90-DAY PRESCRIPTION BENEFIT
Some plans offer a 90-day prescription
benefit for those drugs you use regularly.
These are referred to as maintenance drugs.
This benefit, called Retail90®, allows you
to get maintenance drugs conveniently
and often at a lower cost through a
participating neighborhood pharmacy
or through a participating home
delivery pharmacy.
You are eligible for Retail90 if you
have already filled your prescription
once at any retail pharmacy or through
an eligible home delivery pharmacy
in the past six months using your
SelectHealth benefit.
Call Member Services or check the
Prescription Drug List to find out if your
medication is eligible for the 90-day
prescription benefit. Member Services
can also tell you what retail or home
delivery pharmacies are participating with
your plan.
DRUGS WITH SPECIAL
REQUIREMENTS
(STEP THERAPY AND
PREAUTHORIZATION)
Certain drugs must meet special
requirements before they are covered. If a
drug requires preauthorization, then your
provider must call us before you purchase
your medication. Prescription drugs
that require preauthorization are listed
on our website and identified on your
Prescription Drug List.
If a drug requires step therapy, your
doctor must first prescribe an alternative
drug. These are generally more cost-
effective and do not compromise clinical
quality. If your doctor feels that an
alternative drug will not meet your needs,
he or she can request an exception. These
drugs are also listed on our website and
identified on your Prescription Drug List.
INJECTABLE DRUGS AND
SPECIALTY MEDICATIONS
Injectable drugs and specialty medications
are covered under your medical benefits.
Some members may also have coverage
for select injectable drugs and specialty
medications as a Tier 4 pharmacy benefit.
These types of drugs may be administered
orally, as a single injection, through an
intravenous infusion, or through an
inhaler or nebulizer. Generally used to
treat an ongoing chronic illness, they
can be given by a medical professional or
through self-administration.
EXCLUDED DRUGS
Not all prescription drugs are covered.
Call us or visit
selecthealth.org
to
learn more.
Note: Some employers may choose a
company other than SelectHealth to
administer pharmacy benefits. For
more information, please refer to your
member materials.
Know your
pharmacy benefits
Total Fitness | spring 2014 |
selecthealth.org
dollars & sense
