All Oregon Employees

About your Prescription Drug Plan

PeaceHealth self-insures this benefit by offering a prescription drug service through PeaceHealth Oregon Region. You will receive a separate prescription card from MedImpact for the prescription benefit.  When your prescription is filled through the PeaceHealth Pharmacies, you will be able to obtain your in-formulary prescriptions for a $7 co-pay for generic drugs and $12 co-pay for brand name drugs. Your co-pay for non-formulary drugs is 50% of the prescription cost. When you need a 90-day supply of your prescription drug, you will only pay 2 co-pays.

You will be able to request your prescriptions by fax, on-line in Crossroads, by phone, or in person when you use the PHOR prescription drug service. Convenient pick-up is available at PHMG Willamette Street and PHMG Hilyard. You may also select home delivery and have your prescription mailed for free.  For your convenience, you may also pick-up refills at the SHMC pick-up center.

If you have your prescriptions filled at one of the other non-PHOR participating pharmacies, your co-pay will be as follows:

• Generic: $7 or 15%, whichever is greater.  If the calculated or contract amount is less than $7, then the calculated or contract amount would apply.
• Brand: $12 or 25%, whichever is greater.  If the calculated or contract amount is less than $12, then the calculated or contract amount would apply.
• All non-formulary: 50%

Out-of-Pocket Maximum

There is an out-of-pocket maximum for prescription benefits of $750.00 per person.  This pertains to formulary prescriptions filled at either a PHOR Pharmacy or a Non-PHOR Participating Pharmacy.  Non-formulary, Infertility drugs, and diabetic supplies are excluded from the out-of-pocket maximum.

Network Pharmacy Benefit

Both generic and brand name drugs are covered benefits. Regardless of the reason or medical necessity, if you request a brand name drug, or if your physician prescribes a brand name drug when a generic is available, you will be responsible for the difference in cost between the brand name and generic drug, in addition to the co-pay. 

In an out-of-area emergency, if a network pharmacy is not available, outpatient prescription drugs purchased at an out-of-network pharmacy will be reimbursed at the preferred pharmacy benefit level, subject to the co-payments outlined in the In Network Benefit Summary. The formulary requirement will be waived in these situations.

Some prescription drugs require prior authorization. A current copy of the drugs requiring prior authorization can be requested from your claims administrator or on the Pharmacy Benefit website available on Crossroads. (Your physician will know which prescription drugs require prior authorization.)   You may also access the formulary drug listing through the Pharmacy Benefit website.

Benefits, Limitations, and Exclusions

Services that are covered include: 

• Necessary refills. The pharmacy plan has the right to require a new prescription when the number of refills has not been specified or appears to be excessive. 

• Prescription drugs that are ordered by a physician or practitioner whose services are covered under the plan for necessary medical treatment of a covered illness, injury, or physical disability. 

• Prescription drugs that are prescribed for use as specifically labeled by the Federal Food and Drug Administration (unless otherwise required by law), and listed in the United States Pharmacopoeia and National Formulary.

For this benefit, "prescription drug" means antigen and allergy vaccines dispensed by a physician; insulin; and any medicine required by the Federal Food, Drug, and Cosmetic Act to bear the legend: "Caution: federal law prohibits dispensing without prescription."

Some limits to coverage include:

• Prescriptions are limited to a supply sufficient for 34 consecutive days or you may purchase a 90-day supply with two copayments when filled through a PeaceHealth Pharmacy.

• You are eligible for a refill once 70% of the prescribed medication has been utilized based on the prescribed dosage.

•  Infertility drugs are covered with a 50% co-pay.  Prior authorization is required.

• Nicotine deterrent products and supplies requiring a prescription are covered for one 90-day treatment per calendar year.

• Not all FDA-approved drugs are covered by the Plan

Services that are not covered include:

• All over-the-counter (non-prescription) drugs and vitamins

• Surgery, prescription drugs and supplies for sex transformation, sexual dysfunction, or sexual inadequacy and mental and psychological evaluations to rule out the presence of any of these disorders

• Fluoride for members over age 10

• Retin-A for conditions other than acne (over age 30 requires prior authorization)

• Nicotine deterrent products and supplies that do not require a prescription

• Topical minoxidil (hair growth stimulant)

• Anorectics (diet pills)

• Administration or injection of any drugs

• Drugs for cosmetic use

• Experimental or investigational drugs, or drugs not generally recognized by the medical community

• Drugs provided at no cost

• Drugs delivered or dispensed by a physician

Click here for more information regarding your Prescription Drug Plan