Using Benefits

Understanding the Basics of Prescription Drug Coverage

Prescription drug coverage is included in all CoOportunity Health plans. All of the plans we offer use a four-tier formulary called the EnhancedRx Drug List.

• “Formulary” is just insurance-speak for a list of prescription drugs that your health plan covers
• The copay amounts you pay for your covered prescription drug depends on the “tier” or category in which your medication is listed.

How Do Four Tiers Work?

Most CoOportunity Health plans in the individual market, small group (1-50) and mid-market large group (51-100) follow this copayment structure for cost sharing at retail pharmacies for a 31-day supply of covered medications.  In addition, many plans offer first-dollar coverage which means that you do not need to satisfy your deductible before prescription drug coverage is available; all you pay out-of-pocket is the copay amount.

It is important to understand the prescription drug coverage before you select a plan and enroll. Some plans in the individual market (catastrophic, bronze) and many HDHP/HSA plans in individual and group have different copay amounts and some require that you meet your plan deductible before prescription drug benefits pay.

Please refer to the Shop for Insurance section of the website if you are evaluating plans.

Enrolled members should refer to the Individual Policy/Benefits Certificate and specific information on Pharmacy Plan Details: log on to access your specific plan information.

Three Advantages of Pharmacy Network Services

66,000 Network Pharmacies

MedImpact is our pharmacy benefits manager (PBM). MedImpact contracts with more than 66,000 pharmacies across the United States. You can search for a pharmacy by name, city, state, zip or specified travel radius.

There are advantages to using a contracted pharmacy:

• The pharmacist files the claim electronically for you; no paperwork is required.
• The pharmacist can check for drug interactions for prescriptions filled at other network pharmacies and can see if prior authorization is needed or if there are quantity limits.
• You pay the appropriate cost share based on your benefits when you pick up your prescription. You won’t need to pay the entire cost and then wait for reimbursement.