Pharmacy (AK, SYS, WHA) Prescription Drug Plan

All Alaska & Washington Employees (except LCR)

About your Prescription Drug Plan

PeaceHealth self-insures this benefit by offering a prescription drug service through MedImpact. Your medical ID card from Healthcare Management Administrators (HMA) will also be used for the prescription benefit.  Benefits will be provided as described below for state and federal legend drugs requiring a prescription and for other items as specifically provided, when such drug or other items are furnished at an approved pharmacy.  Benefits are subject to any limitations and exclusions.

Legend drugs are those drugs which cannot be purchased without a prescription written by a physician or other lawful prescriber and include compound medications in which at least one ingredient is a legend drug.

Retail & Mail Order Prescription Benefit - Network Pharmacies 
  In-Network & Open
Network Plus Plans
 
Open Network
Plan
 
Mail Order
(90 day supply)
 
Generic  $10 copay  15%  $14 copay 
Formulary Drugs  $20 copay  25%  $30 copay 
Non-Formulary Drugs  50%  50%  50% 
Combined retail and mail order $1000/person out-of-pocket maximum. Out-of-pocket maximum excludes non-formulary and diabetic supplies.  No out of network benefit. 

 

Generic Drugs

This Plan requires the pharmacist to fill the prescription with a generic product whenever it is available, unless the prescription is written "Dispense as Written."  In this case, the co-pay will be in addition to the cost difference between the brand and generic.

Maintenance Drugs

A 90-day supply of maintenance drugs is available through the PeaceHealth mail order service.  Using the mail order service reduces your out-of-pocket costs.

Eligible Providers

You may obtain prescription drugs under this Plan only from MedImpact Pharmacies and the PeaceHealth mail order service.

If you purchase a prescription drug from a pharmacy that is not an eligible provider (non-network pharmacy), you will not be entitled to any reimbursement under this Plan unless it is due to an out-of-area emergency.

Prior Authorization

Some prescription drugs require prior authorization. Drugs requiring prior authorization may be found on the Pharmacy Benefit website on Crossroads.

Drugs Covered

The Plan provides a three-tiered benefit and is applied to a formulary.  In most instances, generally available drugs will be covered on the first or lowest tier, brand drugs on the formulary will be covered under the middle tier and drugs not on the formulary list (non-formulary drugs) will be covered under the third highest tier.

The following is a list of those drugs covered by the Plan:

  • Legend drugs.  Exceptions:  See Exclusions below.
  • Insulin
  • Disposable insulin needles/syringes
  • Disposable blood glucose/testing agents (e.g., Chemstrips)
  • Any other drug which under the applicable state law may only be dispensed upon the written prescription of a physician or other lawful prescriber.          

Services that are covered include: 

  • Necessary refills. The pharmacy plan has the right to require a new prescription when the number of refills has not been specified or appears to be excessive. 
  • Prescription drugs that are ordered by a physician or practitioner whose services are covered under the plan for necessary medical treatment of a covered illness, injury, or physical disability. 
  • Prescription drugs that are prescribed for use as specifically labeled by the Federal Food and Drug Administration (unless otherwise required by law), and listed in the United States Pharmacopoeia and National Formulary.

For this benefit, "prescription drug" means antigen and allergy vaccines dispensed by a physician; insulin; and any medicine required by the Federal Food, Drug, and Cosmetic Act to bear the legend: "Caution: federal law prohibits dispensing without prescription."

Exclusions and Limitations

Some limits to coverage include:

  • Prescriptions are limited to a supply sufficient for 34 consecutive days or you may purchase a 90-day supply with two copayments when filled through the PeaceHealth mail order service.
  • You are eligible for a refill once 70% of the prescribed medication has been utilized based on the prescribed dosage.
  • Nicotine deterrent products and supplies requiring a prescription are covered for one 90-day treatment per calendar year.
  • Not all FDA-approved drugs are covered by the Plan

Services that are not covered include:

  • Over-the-counter (non-prescription) drugs and vitamins except as approved by the plan (see Formulary for specific information)
  • Infertility drugs
  • Prescription drugs and supplies for sex transformation, sexual dysfunction, or sexual inadequacy
  • Fluoride for members over age 10
  • Retin-A for conditions other than acne (over age 30 requires prior authorization)
  • Nicotine deterrent products and supplies that do not require a prescription
  • Topical minoxidil (hair growth stimulant)
  • Anorectics (diet pills)
  • Administration or injection of any drugs
  • Drugs for cosmetic use
  • Experimental or investigational drugs, or drugs not generally recognized by the medical community
  • Drugs provided at no cost
  • Drugs delivered or dispensed by a physician

Coordination of Benefits

Coordination of Benefits does apply to this Plan.