HealthChoice Pharmacy Benefit
The member is responsible for the appropriate copay or the actual cost of the prescription; whichever is less, when a Network Pharmacy is utilized. Only the costs of generic medications are covered unless there is no generic equivalent available. If a generic medication is available, but the member requests the brand name equivalent, the member will be responsible for the copay amount plus the cost difference between the brand name medication and the generic equivalent. Some medications require prior authorization or may have quantity limits. Please contact the Pharmacy Benefits Manager, Medco at 1-800-903-8113, for information regarding quantity limits and to obtain prior authorization.
A list of preferred medications is included in the HealthChoice Select Medication List. A copy of this medication list is available on the provider website or you may request a list through the Provider Relations Division.
HealthChoice Select Medication List (HSML)
The HealthChoice Select Medication List is based on optimum therapy strategies and the evaluation of clinically equivalent medications. These evaluations are performed by the pharmaceutical consultant for OSEEGIB and the clinical staff of the pharmacy benefits manager. A list of preferred and non-preferred medications has been established and members obtain preferred medications (medications included on the Select Medication List) by paying the cost of the medication up to a $25 maximum if the cost of the medication is $100 or less. If the cost of the preferred medication is over $100, the member pays 25% of the cost up to a maximum of $50.
Members obtain non-preferred medications (medications not included on the Select Medication List) by paying the cost of the non-preferred medication up to a $50 maximum if the cost of the medication is $100 or less. If the cost of the non-preferred medication is greater than $100, the member pays 50% of the cost up to a maximum of $100.
HealthChoice is a generic mandatory Plan. If the member chooses a brand-name medication with generic alternatives, the member is required to pay the difference in cost between the generic and the brand-name medication.
Prior Authorization Process for Non-Preferred Medications
Prior authorization is required when a provider deems it necessary and appropriate to utilize a medication that is not contained in the Select Medication List. The prior authorization process is used to establish that a particular case meets clinically driven, medically relevant criteria before the medication is approved for coverage at the preferred rate.
The following process will be initiated for providers requesting prior authorization for a non-preferred medication at the preferred rate:
- The provider’s office should contact Medco at 1-800-753-2851. Please have the Member ID number (Social Security Number) and the medication name and fax number ready to give to the Medco representative.
- Medco will fax a prior authorization form to the provider’s office. This form should be completed at the provider’s office. Call Medco at 1-800-753-2851 to obtain the appropriate fax number.
- The provider’s office will receive a fax from Medco which will supply notification of the review results.
- If the medication is approved for coverage under the preferred rate, the approval is loaded into Medco’s system within 24 to 48 hours. Written notification of the approval is faxed to the provider’s office and sent to the member within 24 to 48 hours. If a non-preferred medication is not approved through the prior authorization process, written notification is also faxed to the provider and sent to the member within 24 to 48 hours.