PeaceHealth self-insures this benefit by offering a prescription drug service through PeaceHealth Oregon Region. Your medical ID card from Healthcare Management Administrators (HMA) will also be used 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 $15 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 the Willamette Street pharmacy. You may also select home delivery and have your prescription mailed for free.

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

• Generic: $10 or 15%, whichever is greater.  If the calculated or contract amount is less than $10, then the calculated or contract amount would apply.
• Brand: $20 or 30%, whichever is greater.  If the calculated or contract amount is less than $20, 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 $1000 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 copay. 

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 copayments outlined in the In Network Benefit Summary. The formulary requirement will be waived in these situations.

Prior Authorization

Some prescription drugs require prior authorization. Drugs requiring prior authorization may be found on the Pharmacy Benefit website on Crossroads or by calling 541-687-6165 or 877-216-5026.

Drugs Covered

The Plan provides a three-tiered benefit and is applied to a formulary.  In most instances, generally available drugs will be covered on the first or lowest tier, brand drugs on the formulary will be covered under the middle tier and drugs not on the formulary list (non-formulary drugs) will be covered under the third highest tier.

The following is a list of those drugs covered by the Plan:

• Legend drugs.  Exceptions:  See Exclusions below.
• Insulin
• Disposable insulin needles/syringes
• Disposable blood glucose/testing agents (e.g., Chemstrips)
• Any other drug which under the applicable state law may only be dispensed upon the written prescription of a physician or other lawful prescriber.          

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."

Exclusions and Limitations

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:

• Over-the-counter (non-prescription) drugs and vitamins except as approved by the plan (see Formulary for specific information)

• Prescription drugs and supplies for sex transformation, sexual dysfunction, or sexual inadequacy

• 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

Coordination of Benefits

Coordination of Benefits does apply to this Plan.