Marketplace Pharmacy & Drugs

Every FirstCare Marketplace plan includes benefits for your prescription drugs. These prescription drug benefits offer broad prescription drug coverage, and allow you to share in the savings when you and your doctor decide on certain medications.
 

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

Our Pharmacy Networks

You’ll discover that FirstCare’s extensive network of local pharmacies gives you a great advantage when trying to fill your prescriptions. Remember to check back before filling your prescriptions in case there’s been a change to the list. To view our online pharmacy network directory search tool, click here.

Our Formulary

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.



 

The Tier System

All FirstCare Marketplace 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 no-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

 

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 non-preferred status with a corresponding 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 hightest tier drug copayment level.

If you have any questions, contact a FirstCare representative or ask the Pharmacist.