TRS Pharmacy Benefit
Your FirstCare HMO health plan includes a prescription drug benefit. This benefit program provides broad prescription drug coverage, and allows you to share in the savings when you and your doctor decide on certain medications.
All drugs covered under this benefit plan are assigned to one of the following three copayment tiers:
- Tier 1: Lowest copayment for Generic Drugs
- Tier 2: Higher copayment for a limited list of Brand Name Drugs
- Tier 3: Higher copayment than Tier 2 for other Brand Name Drugs
- Tier 4: Self-Injectables and other High Technology Drugs - Injectable medications are those recognized by the FDA as appropriate for self-administration regardless of the Member's ability to self-administer.
A panel of physicians and pharmacists (The Pharmacy & Therapeutics Committee), who evaluate the various drugs available to treat specific conditions and assigns covered drugs on one of the copayment tiers. Certain medications require Prior Authorization in order to be a covered benefit. In addition, some classes of drugs are subject to quantity dispensing limitations. Periodically, the Drug Coverage List may be reviewed as new drugs and drug therapies are introduced
4-Tier Prescription Benefits Sample of Savings
What you pay for drugs with your prescription benefits is often a fraction of the cost you would pay without it.(example: copayments of $10/$20/$40/25%)
4-Tier Levels Drug Name
What you might pay: without coverage with coverage
| 1 |
Tamoxifen |
$52 |
$10 |
| 2 |
Effexor XR |
$106 |
$20 |
|
3 |
Zocor |
$125 |
$40 |
|
4 |
Enbrel |
$1040 |
$260 |
Costs represent a one-month supply, based on a blended average of paid claims.
NOTE: This is a list of the most commonly prescribed drugs. This is a partial list. Please call our Customer Service Center if you have been prescribed a drug that is not on this list to find out on what Tier the drug is covered GENERIC DRUGS, WHETHER LISTED OR NOT, ARE COVERED AT THE TIER 1 COPAYMENT WHEN USED TO TREAT A COVERED MEDICAL CONDITION. Note that not all strengths of these medications are available in a generic version. Check with your pharmacy to verify generic availability. First Data Bank is the drug classification service used to define generic drug status.
More Highlights
- Your specific prescription benefit plan design may not cover certain categories of drugs, regardless of their appearance in this document.
- For specific information regarding your prescription coverage, please call a FIRSTCARE Customer Services Representative at (800) 884-4901, or refer to your Evidence of Coverage.
- 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.
- 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 non-covered status with a corresponding higher out-of-pocket cost. The generic equivalent drug is automatically covered at the generic drug copayment.
- Newly approved FDA drugs are automatically placed on the Tier 3 drug copayment level if used to treat a covered medical condition.
- The Drug Coverage List is subject to change. However, a drug will not be removed from this List without you having first received notice in advance of such removal.
Mail Order Prescription Drugs
FirstCare provides our members the ability to obtain prescriptions through mail order. Mail order copayments allow for up to a 90 day supply. View and print our mail order forms:
- Maxor (pdf, 1.74 MB) - Amarillo and Lubbock Service Area
- Express Scripts (pdf, 509 kb) - Abilene and Waco Service Area
12940 N. Hwy 183
Austin, Texas 78750
(512) 257-6000
(800) 431-7737