Employers

Group Administrator's Manual

Pharmacy Program

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Overview

In an effort to help hold the line on escalating prescription medication costs, Arkansas Blue Cross provides a Pharmacy Program to help maintain quality health care.

The information in this section will give you an overview of the Pharmacy Program and help you find answers to questions about how employees can best use their pharmacy benefits. Specific details about each employee's pharmacy benefits should be discussed with a Caremark customer service representative.

The Pharmacy Program is designed to eliminate the need for claim forms when using a participating pharmacy. Pharmacy claim forms are provided upon request.

The Arkansas Blue Cross/Health Advantage Pharmacy Program, administered through Caremark, contracts with more than 64,000 pharmacies nationwide to ensure employees have access to the medications they need wherever they go.

After a prescription is filled, the pharmacist will store the personal prescription history in a state-of-the art system to alert the pharmacist to dangerous drug interactions, allergies, sensitivities to medications and chronic ailments. These quality assurance measures help to protect the employee and enhance the quality of care.

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Benefits

The Pharmacy Program offers benefits to customers and their covered dependents, including the following:

  • Cost savings
  • No claim forms
  • Nominal copayments and/or coinsurance
  • Specialized customer service
  • Access to an extensive pharmacy network

When an employee presents an ID card, participating pharmacists (working with the employee's physician) can closely monitor medication therapy.

Pharmacists will be able to determine whether:

  • The medication to be dispensed may combine in a harmful way with another medication currently prescribed.
  • A prescription duplicates another prescription.
  • The dosage or amount is being over used or under used.

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ID Cards

Arkansas Blue Cross members will receive an ID card to be used for both medical and pharmacy.

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Covered Medications

The Pharmacy Program generally covers most medications that require a prescription from a physician or other legally qualified person. Covered medications include:

  • FDA-approved prescription medications.
  • Prescriptions filled by a participating pharmacy.
  • Insulin and insulin syringes.
  • Some injectable medications, if approved in advance.

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Medications Not Covered

Medications not covered by the pharmacy program vary according to the group's benefit package. Please refer to your benefit certificate and Schedule of Benefits for more information about each plan.

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Using the Program

Employees with the Pharmacy Program benefit have access to thousands of participating pharmacies throughout the nation, including most local and national chain pharmacies. Participating pharmacies collectively are referred to as the pharmacy network.

To find a participating pharmacy, employees may ask their pharmacists if they are members of the Caremark network, or call the toll-free number on their ID card for information on the nearest participating pharmacies. Access to the online pharmacy locator can be found at: www.arkansasbluecross.com.

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Participating Pharmacy Procedure

When employees go to a participating pharmacy to have their prescription filled, they must present their ID card to the pharmacist along with their prescription. At the time of purchase they will be expected to pay coinsurance and/or a copayment and/or deductible, based on their group's Schedule of Benefits. The pharmacist will submit an electronic claim for reimbursement for the remainder of the payment.

There are no claim forms to complete, but employees will be asked to sign a log at the pharmacy as evidence they received the medication for insurance verification.

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Non-Participating Pharmacy Procedure

In State

If an employee uses a nonparticipating pharmacy in their state of residence, the prescription is not covered through the Enterprise Pharmacy Program and is not eligible for reimbursement from the insurer.

Out of State

If an employee uses a nonparticipating pharmacy outside their state of residence, the prescription is not covered throughout the Pharmacy Program and is not eligible for reimbursement from the insurer.

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Generics vs. Brand-Name Medications

Choosing generic medications, rather than brand names, will save your employees money.

Brand-name medications are those for which a pharmaceutical company holds a patent. After the patent expires, other manufacturers may produce the same drug. These medications bear the same chemical or generic name and, by law, must meet the same standards for purity, strength, quality and safety.

Generic medications are therapeutically equivalent to the original brand name but usually cost significantly less. When employees select the less expensive generic form of a medication, they save money by reducing the copayment and/or coinsurance amount they pay.

Most groups have a generic incentive as part of their benefit package. The generic incentive works this way:

  • When a brand-name medication is dispensed and there is no generic available that is suitable for substitution, or the physician has indicated on the prescription "dispense as written," the employee pays the brand-name copayment and/or coinsurance.

  • If a brand medication is dispensed when a generic medication is available and the physician has not indicated "dispense as written," the employee will pay the coinsurance (if applicable) and the second- or third-tier copayment plus the difference in price between the generic and the brand dispensed, or the cost of the medication, whichever is less.

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Where to Call for Help

The toll-free number for Caremark (1-800-863-5561) is on the back of your employees' ID cards. Caremark can provide information on:

  • Participating pharmacies

  • Covered and non-covered medications

  • How to receive additional claim forms

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Frequently Asked Questions

Q. How does the employee use the ID card at the pharmacy?
A. The member gives the pharmacist a health plan ID card when requesting the prescription (new or refill). The employee provides the pharmacist with: patient name, date of birth and gender. The employee pays the pharmacist the appropriate amount (deductible or copayment and/or coinsurance) in accordance with the group's benefits.

Q. Why should the employee use a participating (network) pharmacy?
A. The employee receives maximum benefits (and processing convenience) when using a participating pharmacy.

Q. What if the employee obtains a prescription medication from a nonparticipating (non-network) pharmacy?
A. If an employee uses a nonparticipating pharmacy, the prescription will be denied.

Q. How do employees get prescriptions filled when traveling?
A. When employees plan to travel out of state and are on maintenance (ongoing, planned) medication, they may be able to obtain enough medication to last until they return home by contacting their usual pharmacy in advance.

If an employee becomes ill or injured while traveling, he or she may use any network pharmacy; he or she will need to show the pharmacist a health plan ID card.

The network pharmacy can submit the claim electronically and the employee will pay a copayment.

The employee also can pay for the medication "out-of-pocket" and submit a claim for reimbursement later.

Note: Employees should ask if the pharmacist is a member of the Caremark network; it may save them the trouble of filing.

Q. Can a family member pick up an employee's prescription?
A. Yes, another responsible member of the family may obtain the medication at the employee's request.

Q. Do purchases of prescriptions with the pharmacy program go toward meeting the calendar-year coinsurance maximum?
A. No.

Q. On a newly enrolled group, does the deductible that an employee met with a previous carrier count toward meeting the pharmacy program deductible (if any)?
A. Meeting a drug deductible with a previous carrier does not count towards the annual drug card deductible when a group enrolls with Arkansas Blue Cross.

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