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Pharmacy Program
Prescription Benefit Options Within A Partially Self-Funded Plan
| | With a Partially Self-Funded Plan, whether a “Medical Expense Reimbursement Plan” (MERP) or a “Health Reimbursement Arrangement” (HRA), there are two options for accessing, managing and administering the prescription drug benefit.
A. Direct Member Reimbursement. OptiLife members who obtain medication and pay the full amount at the time of service may submit a copy of their prescription receipt (not cash register receipt) to OptiLife for reimbursement processing.
B. AVIA Card Discount Program for plans with paper Rx claim submission (Nationwide Plan 5):
1. The AVIA program includes a discount off the wholesale price of prescriptions when using a network pharmacy. This discount (based on the Average Wholesale Price of prescriptions) could result in overall savings when compared to prescriptions obtained at full retail price.
2. Approximately 90% of all pharmacies participate in the AVIA network, allowing greater pharmacy access.
3. Employer groups can choose to obtain the AVIA card for employees for purpose of utilizing the discount program only. This means the employee would pay 100% of the cost of the medication at the lower of the discounted rate determined by AVIA or the pharmacy's "usual and customary" rate.
4. There is a nominal $1.25 per transaction fee to utilize the AVIA discount network which is paid by the employer.
5. OptiLife currently uses an open-formulary model with AVIA. However, a Drug Formulary can be implemented with AVIA should an employer choose this option.
· Customary Procedure for plans requiring paper claim submission:
1. Present your plastic AVIA Card to the pharmacy. DO NOT USE THE CARRIER's ID CARD.
2. You will be charged your regular OptiLife coinsurance amount at the pharmacy.
3. OptiLife will forward the paper pharmacy claims to the Primary Carrier so that the charges can be credited to your Primary Carrier deductible.
· If Employer Annual Maximum Benefit has been met:
1. Once your Employer Annual Maximum Benefit (individual/family) is met, the OptiLife / AVIA coinsurance program has been fulfilled.
2. Continue to show your AVIA Card to be sure to get your discounted rate.
3. You will pay 100% of the discounted charge at the pharmacy and will then be reimbursed at your coinsurance rate (typically 70% or 80%) by the Primary Carrier directly.
4. OptiLife will continue to submit your claims to the Primary Carrier on your behalf. The turn-around time for the reimbursement process from the Primary Carrier is generally 6-8 weeks.
C. AVIA Card Discount Program for plans with primary electronic claim submission (Blue Cross, Blue Shield)
1. Show your Carrier's ID card (Blue Cross, Blue Shield). The pharmacist will enter this into their system as the primary billing number.
2. Show your AVIA Card and mention that this card is for secondary coverage. The pharmacist will enter the AVIA information as the secondary billing numberr, which will be used during the "split billing" process.
3. The Carrier will determine the discounted price, and the AVIA card will determine how much you have to pay of that price. The employer will pay the balance through OptiLife's billing arrangement with AVIA.
4. Once your primary carrier deductible has been satisfied, the plan will revert to the carrier's copayment amounts.
· Drug Formulary. Some primary carrier insurance companies require utilizing a Drug Formulary within the benefit structure. A Drug Formulary is a drug list that has been developed by an organization for use by physicians and members in an effort to contain cost. A Formulary Committee (made up of physicians and pharmacists) decides which drugs to include on the formulary after evaluating them for therapeutic uniqueness, safety, and cost. The following criteria is commonly used in the evaluation of product selection for a Drug Formulary:
· Product safety profile
· Product efficacy
· Product effectiveness
· Comparison of relevant product benefits to current formulary agents of similar use, while minimizing duplication
· Equitable cost and outcomes of the total cost of product and medical care
With a Drug Formulary, there is usually a difference in the member’s co-pay or co-insurance between a generic drug and a brand-name drug. Generic drugs are evaluated by the Food and Drug Administration and undergo the same scrutiny as brand-name drugs. A generic-equivalent drug must have the same active ingredients and be chemically equivalent to the brand-name drug. Generic drugs are usually less expensive than brand-name drugs.
Prior Authorization may be required if a prescribed medication is not listed on the insurance company’s Drug Formulary. Prior authorization for medication requires either the pharmacist or prescribing physician to contact the insurance carrier and provide a basis of medical necessity for the non-formulary medication. If prior authorization is not obtained, the member could be responsible for the entire cost of the medication. | |
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