Before Filling Your Prescription at the Pharmacy

Step 1

Lookup your prescription on the Blue Rx Value Plus℠ Drug List or Call Wellmark at 1-800-355-2031.

Step 2

Is the "medication" covered under your insurance benefit?

1. No - If the prescription does not show up on the Blue Rx Value Plus℠ 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.
2. Yes - Proceed to step 3.

Step 3

Does the "medication" require prior authorization?

If the Blue Rx Value Plus℠ 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.

1. No - Proceed to step 4.
2. 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?

1. 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 Plus℠ Drug List or the Wellmark representative will tell you the Tier level.
2. 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 Plus℠ Drug List or the Wellmark representative will tell you the Tier level.
   1. If your doctor recommends that you use a brand name drug (even though there is a generic available)
      1. 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.
         1. 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.

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.

★ 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 Plus℠ prescription drug benefits. To determine whether a particular specialty drug is covered under your medical benefits or under your Blue Rx Value Plus℠  prescription drug benefits, consult the Blue Rx Value Plus℠ 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.

Note: To determine if a drug is covered, you must consult the Wellmark Blue Rx Value Plus℠ Drug List or utilize the Check Drug Cost tool through caremark.com. You are covered for drugs listed on the Wellmark Blue Rx Value Plus℠ Drug List. If a drug is not on the Wellmark Blue Rx Value Plus℠ Drug List, it is not covered. To easily find your prescription on the Wellmark Blue Rx Value Plus℠ Drug List, from a computer, enter your prescription name in the search field.

• 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.
• Coinsurance
  Your share of the costs of a covered health care service, calculated as a percent of the allowed amount for the service.
• Co-pay
  A fixed amount you pay for a covered health care service, usually when you receive the service.
• Prior Authorization (PA)
  This indicates a drug requires prior authorization before it is covered under your health plan. 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.
• In-Network
  Providers who contract with your health plan. Co-payment may be less when seeking treatment in-network.
• Out-of-Network
  Providers who do not contract with your health plan. Co-payment may be higher if seeking treatment out-of-network. Your out of pocket expense may be significantly higher due to the Product Selection Penalty.
• Tier
  Drug tiers are how prescription drugs are divided into different levels of cost. Drugs in Tier 1 will be your cheapest options.

• How can I use the Prescription Drug List to save money?
• Why do we have a Prescription Drug List?
• Why is my prescription not on the Prescription Drug List?
• Who decides what medications go on the Prescription Drug List?

• CVS Caremark Mail Order Pharmacy Services
• CVS Caremark Mail Order Pharmacy Overview Flyer
• CVS Caremark Prescription Drug Cost, Coverage, and Locator Tool