Own Your Benefits
Before Filling Your Prescription at the Pharmacy
The following steps and prescription information can help you make wiser and more financially sound decisions at the pharmacy. By researching now, this will in turn reduce your stress when picking up a filled prescription.
Step 1
Lookup your prescription on the Blue Rx Value PlusSMDrug List or Call Wellmark at 1-800-355-2031.
Step 2
Is the "medication" covered under your insurance benefit?
- No If the prescription does not show up on the Blue Rx Value Plus SM Drug List or the Wellmark representative tells you it is not covered, there is no coverage for this medication. You will pay the entire cost of the medication.
- Yes Proceed to step 3.
Step 3
Does the "medication" require prior authorization?
If the Blue Rx Value PlusSM Drug List or the Wellmark representative indicates the prescription is classified as PA - Prior Authorization, this indicates a drug requires prior authorization before it is covered under your health insurance. Your health care provider will need to contact our Pharmacy program at 800-600-8065. Hours of operation are Monday- Friday: 8 a.m. to 6 p.m. CST.
- No Proceed to step 4.
- Yes Ask your doctor to call Wellmark with the necessary prior authorization information. Proceed to step 4.
Step 4
Is there a covered generic available?
- No What Tier is this brand name drug in for your plan and what is your co-pay? The Tier information is located on the Blue Rx Value PlusSMDrug List or the Wellmark representative will tell you the Tier level.
- Yes What Tier is this generic drug in for your plan and what is your co-pay? The Tier information is located on the Blue Rx Value PlusSM Drug List or the Wellmark representative will tell you the Tier level.
- If your doctor recommends that you use a brand name drug (even though there is a generic available)
- UNI PPO (Alliance Select) and UNI Blue Advantage (HMO) - In most cases, when you purchase a brand name drug that has an FDA –approved generic equivalent, Wellmark will pay only what it would have paid for the equivalent generic drug. You will be responsible for your payment obligation for the equivalent generic drug and any remaining cost difference up to the maximum allowed fee for the brand name drug, this is called Product Selection Penalty.
- Even if your physician prescribes the brand name, and writes "dispense as written", the penalty will still apply. Any amount you pay for the cost difference does not go towards your maximum out of pocket.
- UNI PPO (Alliance Select) and UNI Blue Advantage (HMO) - In most cases, when you purchase a brand name drug that has an FDA –approved generic equivalent, Wellmark will pay only what it would have paid for the equivalent generic drug. You will be responsible for your payment obligation for the equivalent generic drug and any remaining cost difference up to the maximum allowed fee for the brand name drug, this is called Product Selection Penalty.
- If your doctor recommends that you use a brand name drug (even though there is a generic available)
Step 5
Did you ask if the medication can be written as a 90-day prescription?
If your prescription can be filled as a 90 day supply, it may qualify for the CVS Caremark Mail Order Pharmacy Service. This service allows a 90-day supply of maintenance medications to be mailed directly to you. You are also able to set up automatic refills.
A 90-day supply using mail service typically costs less than multiple copayments dispensed at a retail pharmacy.
| Prescription | UNI Blue Advantage (HMO) |
UNI PPO (Alliance Select) |
||
|---|---|---|---|---|
| Co-pay | Co-pay | |||
| In-Network | Out-of-Network | In-Network | Out-of-Network | |
| Tier 1 Most generic drugs and some brand-name drugs that have no generic equivalent. |
$10 | In-Network + *Balance Billed | $10 | In-Network + *Balance Billed |
| Tier 2 Typically brand name formulary drugs with no generic equivalent or are considered less cost-effective than Tier 1 drugs. |
$30 | In-Network + *Balance Billed | $30 | In-Network + *Balance Billed |
| Tiers 3 & 4 Typically brand name non-formulary drugs that are less cost-effective than Tier 1 or Tier 2. |
$50 | In-Network + *Balance Billed | $50 | In-Network + *Balance Billed |
| Specialty Biosimilar A biosimilar, or biosimilar drug, is a medicine that is very close in structure and function to a biologic medicine. |
$75 | In-Network + *Balance Billed | $75 | In-Network + *Balance Billed |
| **Specialty Preferred Drugs - Specialty drugs available as combination products or lifestyle drugs. |
$115 | In-Network + *Balance Billed | $115 | In-Network + *Balance Billed |
| **Specialty Non-Preferred Drugs - Specialty drugs available as combination products or lifestyle drugs. |
$215 | In-Network + *Balance Billed | $215 | In-Network + *Balance Billed |
| ***Mail Order | 2 co-pays for a 90 day supply (maintenance drugs only) | |||
| Out of Pocket Max | $2,600 per person $5,200 per family |
$2,600 per person $5,200 per family |
||
*Balance Billed - Non-participating and Non-network providers can balance bill the member for the difference between their charge and the allowed amount. This balance bill is the member’s liability and does not apply to the deductible or out-of-pocket maximum.
**Specialty drugs may be covered under your medical benefits or under your Blue Rx Value PlusSM prescription drug benefits. To determine whether a particular specialty drug is covered under your medical benefits or under your Blue Rx Value PlusSM prescription drug benefits, consult the Blue Rx Value PlusSM Drug List at Wellmark.com, or call the Customer Service number on your ID card.
***Mail Order Drugs - save time and money by using mail order pharmacy for the prescriptions you take regularly. With mail order, you'll receive a 90-day supply, which typically costs less than multiple co-payments of the same quantity. Log into caremark.com to see if your prescriptions qualify for the mail order program. You can also utilize the check drug cost tool through your account on caremark.com to see what your prescription would cost you with your insurance plan, as well as to see if there are cheaper alternatives available.
If you use a Non-Participating Pharmacy: UNI Blue Advantage (HMO) & UNI PPO (Alliance Select - You must pay the amount charged as the time of purchase, and then you must file a claim. Once you submit a claim, you will be reimbursed up to the maximum allowable fee of the drug, less your co-payment. The maximum allowable fee may be less than the amount you paid. In other words, you are responsible for any difference in cost between what the pharmacy charges you for the drug and our reimbursement amount. Your payment obligation for the purchase of a covered prescription drug at a participating pharmacy is the lesser of your co-payment, the maximum allowable fee, or the amount charged for the drug.
Please note: To determine if a drug is covered, you must consult the Wellmark Blue Rx Value PlusSM Drug List or utilize the Check Drug Cost tool through caremark.com. You are covered for drugs listed on the Wellmark Blue Rx Value PlusSM Drug List. If a drug is not on the Wellmark Blue Rx Value PlusSM Drug List, it is not covered. To easily find your prescription on the Wellmark Blue Rx Value PlusSM Drug List, from a computer, enter your prescription name in the search field.