MMEHT has a five-tier prescription drug program. The five tier program includes a Tier 1-Select Generic category with a lower copayment for many common drugs and Tier 1-Standard primarily for generic drugs. Tier 2 and Tier 3 medications are typically name brand drugs with slightly higher copayments. Tier 4-Specialty and Lifestyle is for the highest cost medications. The Health Trust’s prescription drug program is administered by IngenioRx.

 

Prescription Drug Resources

 

Prescription Co-Pays

The member responsibility (co-pay) for your prescription will vary depending on the Tier the drug is included in, and the medical plan that you participate in.  To verify the Tier of a particular drug, please refer to the Current Prescription Drug Listing, above or contact Member Services.  Please refer to the individual medical plan descriptions for the prescription co-pays for your specific plan.

 

How are the tiers determined?

Our health plans use a “Preferred Drug List” containing brand-name and generic medicines approved by the Food and Drug Administration (FDA) and reviewed and recommended by Anthem’s Pharmacy and Therapeutics (P&T) Committee.  The P&T Committee is an independent group of practicing doctors, pharmacists and other health care professionals responsible for the research and decisions surrounding our drug lists. This group regularly meets to review new and existing drugs and chooses the medicines for our drug lists for several reasons, including their safety, value and how well they work.

Drugs on the Drug List are grouped into tiers. There are several factors that are used to determine under which tier a drug will be put in. This can include (but it’s not limited to):

  • Cost of the drug
  • Cost of the drug in comparison to other drugs used for the same type of treatment
  • Availability of over-the-counter options
  • Other clinical and cost factors.

When you use the prescription medications on the “preferred” list, or formulary, you will pay a lower copay than if you were using medications that are considered as “non-preferred” by Anthem.  Most generic medications are included in Anthem’s formulary, and are subject to one of the lower copays in the program.  The formulary also includes many brand name medications, for which you will usually pay a higher copay.    Certain prescription drugs may be excluded when better value, clinically-equivalent medications in the same therapeutic class are available.  Please contact MMEHT at 1-800-852-8300 for more information.

 

How will I know in which tier my drug falls?

Tier 1 Select drugs offer the greatest value within a therapeutic class. Tier 1 Select medications are the most commonly prescribed and proven medications that are known for effectiveness and value in treating many medical conditions. You can review the current listing of the Tier 1 Select drugs to see if your medication falls under this tier: Tier 1 Generic List.

Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. This approval process is called prior authorization. Please call Health Trust Members Services if you have questions about this process.

If you have a health problem that needs to be treated with complex drugs, your medication may fall into the Specialty drug tier. Specialty drugs are those drugs that come in different forms including oral (i.e., drugs taken by mouth, like pills or liquids) but are often injected, infused or inhaled. They most often need special storage and handling, need clinical monitoring, cost a lot of money and are given to a patient by a doctor or a nurse. You can review the current listing of the Specialty drugs to see if your medication falls under this tier by viewing the Specialty Drug List.

You can also contact the Health Trust at 1-800-852-8300 (in Maine) or 207-621-2645 (out of state) or by email at htservice@memun.org.  The Health Trust Service Representatives can look up your particular medication to see which tier it falls into.

 

How can I save money through Mail Order?

You will be charged a copay for each 30-day supply of medications purchased at a retail pharmacy (that is, three copays for each 90-day supply). However, when you purchase your medications through Anthem’s mail order pharmacy, IngenioRx, you will only have to pay two copays for that same 90-day supply.

By charging three (3) copays for a 90-day supply of medications at the retail pharmacy, but only two (2) copays for a 90-day supply via mail order, the Trust hopes to encourage more members to use the mail order program for their prescription drugs. There is no dispensing fee charged to the Trust for prescriptions purchased via mail order, and there is a greater discount on the price of medications purchased via mail order, so such a change could provide substantial savings to the plan, as well as for you.

Here’s how to get started on filling your prescriptions via mail order:

  • Ask your doctor for a prescription for a 90-day supply of your medication.
  • If this is a new prescription, you may wish to also get a prescription for a 30 day supply, to be filled a retail pharmacy while you wait for your first mail-order to be processed. Prescriptions can be submitted to the mail order pharmacy by mail or fax, or online at www.anthem.com.
  • Place your order.  Log on to www.anthem.com and choose Pharmacy. On your personal pharmacy page, select View Your Prescriptions under Switch to a 90-Day Supply. For the drugs you want to switch to home delivery, choose Switch to a 90-day Supply and then Select Prescriber. You can also add or update your shipping address, shipping options and payment method on this page.
  • Or, you can complete the Prescription Drug Mail Order Form on the Health Trust website and mail the completed form to CarelonRx with your prescriptions.
  • You may also call CarelonRx Home Delivery Pharmacy at 1-833-236-6196.
  • Pay for your prescription.  You can pay by debit or credit card, use your Flexible Spending Account (FSA) debit card, or enroll for electronic funds transfer (EFT) payments. To set up your payments, select Complete your Profile and Communication Preferences from your personal pharmacy page, then Change Payment Method to choose how you’d like to pay, sign up to pay online or add/update your credit card on file.

 

Important things to know about the mail order program:

  • If you purchase a 90-day supply of a prescription medication through the mail order service, you will only be charged two copays. If you purchase a 90-day supply at any retail pharmacy, you will be charged three copays.  Using the mail order program can save you money!
  • The amount of the copay you are charged depends on the tier in which your medication falls.
  • In most cases, your medicine will be sent to your home within two weeks from the time the home delivery pharmacy gets your order.
  • Specialty medications cannot be filled via CarelonRX Home Delivery Pharmacy mail-order.

If you have any questions, you can reach the Health Trust Member Service Representatives at 1-800-852-8300, Monday through Friday, 8 a.m. to 4:30 p.m.