Prescription Copay Designs
Gold Plan
Effective 1/1/2024
|
UT Pharmacy Locations* |
Retail 14 day supply only |
|
| Tier 1 (Generic) | $10.00 | $10.00 |
| Tier 2 (Preferred Brand) | 20% ($60 max) | 30% ($100 max) |
| Tier 3 (Non-preferred Brand) | 30% ($120 max) | 45% |
| 31-90 day supply | 31-90 day supply | |
| Tier 1 (Generic) | $25.00 | N/A |
| Tier 2 (Preferred Brand) | 20% ($150 max) | N/A |
| Tier 3 (Non-preferred Brand) | 30% | N/A |
* UTMC Pharmacies are the required pharmacy for all maintenance medications. You can
receive one 14 day supply at retail per medication per year
*You receive a 15% discount if your prescription is written by a UT Physicians provider
& filled at a UTMC Pharmacy
* If the cost of the drug falls below the copayment then you will only pay the cost
of the drug at UTMC Pharmacies
| PHARMACIES | UTMC Pharmacies are the required pharmacies on the plan. Members may choose to pay the cash price for any medication or quantity at non-UTMC pharmacies. |
| RX DEDUCTIBLES | Does not apply |
| EXCLUDED PRODUCTS | Weight loss agents, diagnostic agents, ED agents, fertility agents, growth hormone, OTC medications (except insulin and testing supplies), cosmetics |
| PRIOR AUTHORIZATIONS (PA) | Any new to market drug, any drug listed on the PA list, Lupron, Botox, Retin-A for
age http://www.utoledo.edu/depts/hr/total-rewards/benefits/docs/prescriptions/CPRX-PriorAuth.pdf |
| SPECIALTY MEDICATIONS | MUST FILL at UT Access Specialty Pharmacy primary (419-383-5763) / Diplomat secondary Website : www.utoledo.edu/outpatientpharmacy/utaccess |
| DISPENSING BRAND NAME WHEN GENERIC IS AVAILABLE The plan requires that pharmacies dispense generic drugs if available when a brand drug is requested by either the provider (DAW1) or the member (DAW2). |
This includes all FDA approved contraceptives. Should the brand name be chosen when
a generic equivalent is available, the member will be responsible for the cost difference
between the generic and the preferred or non-preferred brand drug in addition to the
preferred or non-preferred brand drug copay. The cost difference is not covered by
the plan and will not accumulate towards the member deductible or out-of-pocket maximum. • Members can still pay for the brand name drug. • Brand name drugs will be covered for the following classes of drugs: thyroid medications, anticonvulsants, transplant medications and antipsychotics which will remain Tier-3 copay. |
| DME SUPPLIES | Insulin pump supplies covered at UTMC pharmacies only-Tier 3 Nebulizer machines covered at UTMC pharmacies only-Tier 3 Glucometer- two meters per year- copay at formulary tier |
| COMPOUNDS | Limited to 30 day supply- preferred fill at Buderer (419-873-2800) or Aring Compound corner (419-841-3833) |
| 15% DISCOUNT IF USING UTMC PHARMACIES AND UT PHYSICIANS PROVIDERS | You will receive a 15% discount if your prescription is written by a UT Physicians prescriber and filled at a UTMC Pharmacy. |
| EPI PENS | Total of 2 packs of 2 pens (total of 4 units) per year |
| VACCINES | Covered at UTMC pharmacies only |
| VACATION OVERRIDE/ LOST MEDICATION | 1 per drug per member per year |
| QUANTITY LIMITS | A quantity limit is the highest amount of a prescription drug that can be given to you by your pharmacy in a period of time. List of quantity limits can be found at: http://www.utoledo.edu/depts/hr/total-rewards/benefits/docs/prescriptions/CPRx-QuantityLimits.pdf |
| COST BELOW COPAY | If the cost of the medication is less than the member's copay, the member will pay only the cost of the prescription. This applies to UTMC pharmacies only. |
| ACA COVERED MEDICATIONS | The following medications are covered at zero copay: low dose aspirin products, generic tamoxifen and raloxifene, generic statins, generic prescription bowel prep agents, folic acid supplementation, generic oral fluoride for children, vaccines, generic contraceptives, smoking cessation products, and vitamin D supplementation. |
| FORMULARY | The formulary can be found at: https://www.utoledo.edu/depts/hr/total-rewards/benefits/docs/prescriptions/2021/CPRx-Performance-Formulary.pdf |
Blue Plan Consumer Driven Health Plan (CDHP)
Effective 1/1/2024
| UT Pharmacy Locations* 30 day supply |
Retail 14 day supply only |
|
| Tier 1 (Generic) | $10.00 | $10.00 |
| Tier 2 (Preferred Brand) | 20% ($60 max) | 30% ($100 max) |
| Tier 3 (Non-preferred Brand) | 30% ($120 max) | 45% |
| 31-90 day supply | 31-90 day supply | |
| Tier 1 (Generic) | $25.00 | N/A |
| Tier 2 (Preferred Brand) | 20% ($150 max) | N/A |
| Tier 3 (Non-preferred Brand) | 30% | N/A |
* UTMC Pharmacies are the required pharmacy for all maintenance medications. You can
receive one 14 day supply at retail per medication per year
* You receive a 15% discount if your prescription is written by a UT Physicians provider
& filled at a UTMC Pharmacy
* If the cost of the drug falls below the copayment then you will only pay the cost
of the drug at UTMC Pharmacies
* When you fill prescriptions, you pay the cost of your prescriptions until the deductible
has been met. Once the deductible is met, you pay the copay detailed above. Once the
out-of-pocket maximum has been met, all prescriptions are covered at 100%. The preventative
medication feature provides coverage for certain medications without first meeting
your deductible. See UT HR benefits webpage for current preventative med list.
| PHARMACIES | UTMC Pharmacies are the required pharmacies on the plan. Members may choose to pay the cash price for any medication or quantity at non-UTMC pharmacies, but out of pocket costs will not go toward the deductible |
| RX DEDUCTIBLES | Shared with medical |
| MAXIMUM OUT OF POCKET | Shared with medical |
| EXCLUDED PRODUCTS | Weight loss agents, diagnostic agents, ED agents, fertility agents, growth hormone, OTC medications (except insulin and testing supplies), cosmetics |
| PRIOR AUTHORIZATIONS (PA) | Any new to market drug, any drug listed on the PA list, Lupron, Botox, Retin-A for age http://www.utoledo.edu/depts/hr/total-rewards/benefits/docs/prescriptions/CPRX-PriorAuth.pdf |
| SPECIALTY MEDICATIONS | MUST FILL at UT Access Specialty Pharmacy primary (419-383-5763) / Diplomat secondary Website : www.utoledo.edu/outpatientpharmacy/utaccess |
| DISPENSING BRAND NAME WHEN GENERIC IS AVAILABLE The plan requires that pharmacies dispense generic drugs if available when a brand drug is requested by either the provider (DAW1) or the member (DAW2). |
This includes all FDA approved contraceptives. Should the brand name be chosen when
a generic equivalent is available, the member will be responsible for the cost difference
between the generic and the preferred or non-preferred brand drug in addition to the
preferred or non-preferred brand drug copay. The cost difference is not covered by
the plan and will not accumulate towards the member deductible or out-of-pocket maximum. • Members can still pay for the brand name drug. • Brand name drugs will be covered for the following classes of drugs: thyroid medications, anticonvulsants, transplant medications and antipsychotics which will remain Tier 3 copay. |
| DME SUPPLIES | Insulin pump supplies covered at UTMC pharmacies only-Tier 3 Nebulizer machines covered at UTMC pharmacies only-Tier 3 Glucometer- two meters per year- copay at formulary tier |
| COMPOUNDS | Limited to 30 day supply- preferred fill at Buderer (419-873-2800) or Aring Compound corner (419-841-3833) |
| 15% DISCOUNT IF USING UTMC PHARMACIES AND UT PHYSICIANS PROVIDERS | You will receive a 15% discount if your prescription is written by a UT Physicians prescriber and filled at a UTMC Pharmacy before your deductible is met. Once you have met your deductible the standard copay/ coinsurance will apply and the discount will no longer apply. |
| EPI PENS | Total of 2 packs of 2 pens (total of 4 units) per year |
| VACCINES | Covered at UTMC pharmacies only |
| VACATION OVERRIDE/ LOST MEDICATION | 1 per drug per member per year |
| QUANTITY LIMITS | A quantity limit is the highest amount of a prescription drug that can be given to you by your pharmacy in a period of time. List of quantity limits can be found at: http://www.utoledo.edu/depts/hr/total-rewards/benefits/docs/prescriptions/CPRx-QuantityLimits.pdf |
| COST BELOW COPAY | If cost of medication is less than the member's copay, the member will pay only the cost of the prescription. This applies to UTMC pharmacies only. |
| ACA COVERED MEDICATIONS | The following medications are covered at zero copay: low dose aspirin products, generic tamoxifen and raloxifene, generic statins, generic prescription bowel prep agents, folic acid supplementation, generic oral fluoride for children, vaccines, generic contraceptives, smoking cessation products, and vitamin D supplementation. |
| FORMULARY | The formulary can be found at: https://www.utoledo.edu/depts/hr/total-rewards/benefits/docs/prescriptions/2021/CPRx-Performance-Formulary.pdf |
| PREVENTATIVE MEDICATIONS | Certain medications will be covered at the normal copay before you meet your deductible, the list of those medications can be found here: http://www.utoledo.edu/depts/hr/total-rewards/benefits/docs/prescriptions/CPRx-PrevMedList.pdf |