Available Drugs & Pharmacy Resources

Pharmacy Networks Express Scripts Pharmacy Network  MAXOR Plus Pharmacy Network	Preferred Drug Lists G-Series Drug Coverage List 3-Tier Drug Coverage List 4-Tier Drug Coverage List
Rx Claim Reimbursement Forms Use this claim form to request reimbursement for prescriptions drugs purchased at non participating pharmacies. Express Scripts MAXOR Plus Refer to the back of your ID card to determine your carrier.

 

Your Pharmacy Benefit

Your FirstCare HMO plan or FirstCare PPO 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 four 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*:Radiation Therapy, Immunosuppressive Medications, Chemotherapy and Associated Agents, Injectable Drugs, Medically Infused Medications and Supplies, and High Technology Drugs.

* Your prescription drug benefit may be on a 3-tier copayment plan. 3-tier plans do not have a Tier 4 copayment option.  Drugs assigned to the Tier 4 level on the Drug Coverage List below are covered under your group's Basic Medical Benefit unless otherwise noted.  Please refer to your Medical Benefit Schedule of Copayments to determine if there are copayment amounts for drugs designated as Tier 4.

A panel of physicians and pharmacists, who evaluate the various drugs available to treat specific conditions, 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.

• 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 consult a FirstCare Customer Services Representative at (800) 884-4901, or FirstCare Preferred Customer Service Representative at (800) 240-3270,or refer to your Evidence of Coverage or Certificate of Insurance.
• 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 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. 

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.
• Other newly approved FDA drugs are automatically placed on the Tier 3 drug copayment level if used to treat a covered medical condition
• Self-Injectable and other High Technology Drugs newly approved by the FDA (Food and Drug Administration) are automatically placed on the Tier 4 drug copayment level*.

GENERIC DRUGS, WHETHER LISTED OR NOT, ARE COVERED AT THE LOWEST 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.

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