Pharmacy & Drugs
Our FirstCare plans include a prescription drug benefit. This benefit program offers broad prescription drug coverage, and allows you to share in the savings when you and your doctor decide on certain medications.
Note: Some of our prescription drug plans have a separate medication deductible. This is indicated in your plan’s details.
Getting the Most from Your Benefits
Some tips on maximizing your dollars when it comes to filling your prescriptions include:
- Using in-network pharmacies,
- Staying on the approved drug list (called formulary)
- Use generic medications, when possible
- Mail order for maintenance medications - We partner with pharmacy expert Novixus Pharmacy Services
Work with your doctor to make sure that your prescriptions are part of the approved list for maximum benefits. The list is updated several times a year to keep you safe and to make sure the medications cover the majority of our community. If you use Step Therapy or other protocol mechanisms, be aware that you will need prior authorization.
NOTE: Unless you are affiliated with one of the employer groups specfifed in this section, please visit our Employers section for more pharmacy options and formularies for your employees.
A panel of physicians and pharmacists regularly evaluate the various drugs available to treat specific conditions and assigns covered drugs to one of the tiers mentioned above. Certain medications require Prior Authorization in order to be covered and some drugs are subject to quantity dispensing limits. Please review the Drug Coverage List
periodically, as new drugs and drug therapies are continually introduced.
Our Drug Coverage Lists are subject to change. However, a drug will not be removed from these lists without you having first received advance notice of such removal.
The Tier System
All FirstCare plans include a tiered structure for our prescription drug benefits. A brief explanation of these tiers is below:
- Tier 1 – Selected generic drugs and Affordable Care Act preventative medications
- Tier 2 – Preferred generics and selected brands
- Tier 3 – Preferred brands and non-preferred generics ( typically have similar alternatives in a lower tier )
- Tier 4 – Non-preferred brands and non-preferred generics
- Tier 5 – Specialty and injectable medications
Note: Not all strengths of these medications are available in a generic version. Check with your pharmacy to verify generic availability.
Medispan is the drug classification service used to define generic drug status.
Requesting Brand Name Drugs
If you or your doctor requests a brand name drug when a generic equivalent is available, then for most plans, you will pay the generic copay plus the cost difference between the price of the brand name and generic drug.
The pharmacy may contact your doctor after receiving your prescription to request consideration of another product or generic equivalent, which may result in your doctor prescribing a different brand name or generic equivalent in place of your original prescription.
What is a Change in Benefit Coverage?
If there is a change in your prescription drug benefit coverage from drugs being added or removed from our formulary, you will be notified in advance of any such change(s).
The following situations do not constitute a change in benefit coverage, rather are normal occurrences in the pharmaceutical market:
- Changes in prior authorization clinical criteria approved by the Pharmacy & Therapeutics Committee
- Generic drugs whose classification status changes to Brand Name during the contract period
- Brand name drugs that have new generic-equivalent products available during the contract period automatically move to a higher out-of-pocket cost as the member is responsible for the cost difference if brand is selected
- Other newly approved FDA drugs are automatically placed on the non-preferred brand drug copayment level if used to treat a covered medical condition
- Self-injectable and other high technology drugs which are newly approved by the Food and Drug Administration (FDA) are automatically placed on the highest tier copayment level.
If you have any questions, contact a FirstCare representative
or ask the pharmacist