Prescription Drug Plan
Health Tradition has contracted with SXC effective July 1, 2005 to provide you with
a national network of pharmacies. This allows you to obtain prescriptions conveniently
in your community, or across the country, for the same copayment amount. Simply
present your membership card to your pharmacist to verify whether the pharmacy participates
in the SXC network. If you have questions about whether a specific pharmacy is in
the network, please review our Network Pharmacy Directory above, or call Customer
Service toll-free at 1-877-832-1823.
If you receive a prescription from a non-SXC pharmacy, you will only receive benefits
in an emergency situation. To receive a reimbursement, please contact Customer Service
and they will send you a reimbursement form, or you can print the form directly
from the MMSI Services Web Site.
You will find it under the FORMS tab, under Pharmacy. You will need
to mail this to Health Tradition with a
note of explanation regarding the emergency and why an out-of-network pharmacy was
used.
Your prescription drug plan is based on the
Health Tradition Formulary
. The
formulary is a list of Health Tradition-approved drugs that your health plan will
cover. Health Tradition reserves the right to change the formulary at any time.
Premier, Premier Plus, and Premier One
If you have a prescription for a drug on the Health Tradition Formulary
that is covered under your plan benefits, you pay either the generic or brand name
copayment amount. If a drug is not listed on the formulary or not covered under
the plan, you either will be responsible for the larger non-formulary copayment
or the entire cost of the medication, depending on your plan. Please review your
Summary of Benefit information that outlines member responsibility amounts under
your employer’s benefit.
65Plus
No outpatient prescription drug benefits will be available under 65Plus policies
issued January 1, 2006, or later. 65Plus does not cover prescription medication,
insulin, and supplies associated with the injection of insulin as 65Plus is prohibited
from duplicating coverage available under the Medicare Part D prescription drug
plan.
65Plus policies issued prior to January 1, 2006, for individuals who do not enroll
in a Medicare Part D prescription drug plan, cover prescription medication, insulin,
and supplies associated with the injection of insulin. The Plan pays 80 percent
of the cost for prescription drugs after an annual deductible of $6250 has been
met. This deductible does not apply to insulin. The 65Plus membership card may entitle
you to drug discounts at SXC pharmacies while also tracking how close you are toward
meeting the $6250 deductible. There is no set rate of discount; it varies per prescription
drug and per pharmacy.
Premier, Premier Plus, Premier One, and 65Plus Pharmacy Directory
To locate the closest participating SXC pharmacy, click on the MMSI Services Web
Site . At the home page, click on My Pharmacy, located
in the navigational tool bar. Then click on Pharmacy Search. If you are not registered
with MMSI Services, you may also contact customer service at our toll-free number 877-832-1823
and ask for the SXC pharmacy nearest you.
BadgerCare Plus
Health Tradition does not provide pharmacy benefits for BadgerCare Plus members
as of 2/1/08. Please see BadgerCare Plus Pharmacy
for assistance.
How The Prescription Benefit Works
Premier, Premier Plus, and Premier One
You pay a single copayment for up to a 34-day supply, excluding diabetic supplies.
You may receive a generic drug or a brand name drug without a generic equivalent
for a single copayment. The generic copayment generally is a lower amount than the
brand name copayment. If you receive a brand name drug when a generic equivalent
is available, you pay the generic copayment plus the difference in
price between the brand name and generic drug. Health Tradition encourages you to
discuss your prescription options with your healthcare provider. Please refer to
your Summary of Benefits for exact copayment amounts.
Foreign Travel/Vacation
For questions on prescription coverage while on vacation, please contact Customer
Service toll-free at 1-877-832-1823. Coverage is limited and restrictions apply.
Reimbursement for prescriptions purchased outside the United States is subject to
approved status with the United States Food and Drug Administration. For more information
on your pharmacy benefits, please contact Customer Service toll free at 1-877-832-1823.
Coordination of Benefits
For members who have dual (two or more) insurance policies, Health Tradition does
not offer coordination of benefit for prescriptions. You must choose one of the
policy prescription benefits available to you.