Prescription Drug Coverage Summary 2024
If you enroll in any of the medical plans, you also have comprehensive prescription coverage.
CerpassRx is the UToledo pharmacy benefits partner that administers the plan. Visit CerpassRx.com to create or log into your member portal. From the portal you can access medications, view lower cost alternatives, track your prescription spend and much more.
If you have questions regarding whether a prescription is covered, please visit your CerpassRx member portal or the University of Toledo benefits webpage. Under prescription drug plan and pharmacy, you will find the formulary, prior authorization list, specialty medication list, and the website for the University of Toledo Outpatient Pharmacies.
The University has 4 outpatient pharmacies located on both campuses. These pharmacies are the required pharmacies on the plan. All maintenance medications (prescriptions commonly used to treat conditions that are considered chronic or long term, i.e. blood pressure, diabetes, etc) are required to be filled at UTMC pharmacies. You can get one 14 day supply per medication per year at retail. You may choose to pay the cash price for any medication or quantity at non-UTMC pharmacies. All acute medications can be filled at any pharmacy for up to 14 days.
| Main Campus pharmacy | The Main Campus Pharmacy is located in the University Medical Center on the southwest side of Main Campus, directly across from the Academic and International Houses. The Main Campus Pharmacy offers a variety of services and strives to offer the best care to students and employees. Our compassionate and friendly staff is available to assist employees and students from either campus with their medication needs, and our over-the-counter prices can't be beat! |
| Health Science Campus pharmacy | The University of Toledo Health Science Campus Pharmacy is conveniently located in the beautiful Medical Pavilion on the hospital campus, right next to the Orthopedic Center. The Health Science Campus Pharmacy carries a full line of OTC products and can process accepted third-party insurance cards. Valet parking is available right out front! Students and employees from the main campus are welcome to use this pharmacy as well. |
| UToledo Access pharmacy | Located in the Comprehensive Care Center on Glendale Ave, UToledo Access pharmacy services all your specialty medication needs. UToledo Access offers high quality, personalized services for our members. |
| UTCare pharmacy | The UTCare Pharmacy is located in the Ruppert Health Center on the Health Science Campus of The University of Toledo. They are a closed pharmacy for patients of the Ryan White Clinic. The UTCare Pharmacy has partnered with the Ryan White Clinic to offer specialized care and cost savings to their patients. |
COST SAVINGS
There are many benefits of utilizing UTMC outpatient pharmacies, including a 15% off your copay when you see a UToledo physician who writes you a prescription and you fill it at a UToledo pharmacy!
EXCLUDED PRODUCTS
Products that are excluded from coverage under the prescription benefit include weight loss agents, diagnostic agents, erectile dysfunction agents, fertility agents, growth hormone, over the counter products, cosmetic products, and medications on the CerpassRx “Me Too” exclusion list.
FORMULARY EXCLUDED MEDICATIONS
With the current CerpassRx formulary, there are certain medications that may not be covered under the plan when a clinically appropriate alternative is available. If you or your prescriber feel you meet clinical criteria to continue taking an excluded medication and would like to be considered for a third party, independent clinical review, please email benefits@utoledo.edu.
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 or the member.
- Should a brand name be chosen when a generic equivalent is available, the member will be responsible for the cost difference between the generic and the brand name drug in addition to the drug copay.
- The 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 at their respective tier copay.
DURABLE MEDICAL EQUIPMENT
The plan will cover certain durable medical supplies at University of Toledo Pharmacies. Insulin pump supplies and nebulizer machines will be covered as a Tier 3 copay and diabetic testing supplies will be covered at the respective Tier.
COMPOUNDS
Compounded medications are covered for a 30 day supply at either Buderer Drug Company or Aring’s Compound Corner.
VACATION OVERRIDE/LOST MEDICATION
If a medication is lost or you are going on vacation, you may utilize a vacation or lost medication override at the pharmacy. You are limited to using this one time for each drug each year. Please notify the pharmacy team if you need to utilize this benefit.
VACCINES
UTMC pharmacies provide vaccinations to our employees. Most are no cost with the insurance.
Benefits Specific to the Blue Medical Plan
| Deductible | The prescription deductible is shared with the medical benefit. Once the deductible is met, prescriptions will be covered at their respective tier. |
| Maximum Out Of Pocket | The prescription maximum out of pocket is shared with the medical benefit. Once the maximum out of pocket has been met, prescriptions are covered at 100% and no copay will be required. |
| Preventative Medications | Certain medication will be covered at the normal tier copay before the deductible is med. The list of those medications can be found on the benefits webpage and are included in the appendix. |
Definitions for the Prescription Benefit
| Coinsurance | A specified percentage of the cost of the drug or service that the member is responsible to pay (example: 20% of the cost of the medication). |
| Compounded medications | Compounded medications are ones that are not made or packaged to be dispensed at a traditional pharmacy. Compounded medications are made based on a practitioner’s prescription in which individual ingredients are mixed together in the exact strength and dosage form required by the patient. |
| Copay | A predetermined amount the member pays for each medication or medical service, not related to the cost of the medication or service (example: $7 copay for generic medications; $15 for brand medications). |
| Deductible | The dollar amount a member must pay each year before the plan benefits “kicks in” |
| DAW | An abbreviation for ‘Dispense as Written’. This is done if a doctor decides that his/her patient should receive a brand name medication when a generic is available. A special notation from the doctor is required to qualify. |
| Formulary | The list of medications that are covered under the prescription plan. |
| Maximum Out of Pocket | The maximum dollar amount the member is responsible for within a calendar year |
| Prior authorization | A process that requires a prescriber to fill out paperwork and send it to the insurance company to be evaluated before the medication will be covered under the prescription plan. |
| Prior Authorization List | A list of medication that would need to undergo a prior authorization in order to be covered under the prescription benefit. |
| Tier 1 medication | These are generic medications. They contain the same active ingredient as a brand name and are considered identical in efficacy, safety, side effects, and dosing. These cost significantly less than the Brand name counterpart. |
| Tier 2 medication | These are preferred brand name medications. A brand name drug is a drug that has a trade name and is protected by a patent. This means that only the company holding the patent may sell or produce the medication. |
| Tier 3 medication | These are also brand name medications, but considered non-preferred. This usually means there is a preferred alternative within Tier 2. |
| Specialty Medication List | A list of medications that are designated a specialty. These medications can only be filled at the UToledo Access pharmacy. |