How The Prescription Drug Program Works
This section does not apply to Medicare eligible retirees, Medicare eligible surviving spouses, and Medicare eligible dependents of retirees and surviving spouses.
The Plan includes a co-payment program for prescription drugs. This section summarizes the details of the program and how it works. An enrollee must elect health insurance coverage in order to participate in the prescription drug program. Refer to the sections on Base Coverage and Select Coverage for information on deductibles.
To be covered under the Plan, prescription drugs must be:
Prescribed by a physician,
Dispensed by a licensed pharmacist, and
Found to be medically necessary for the treatment of the participant’s illness or injury.
Participants may purchase medically necessary prescription drugs at participating retail pharmacies, through the mail order service, or through the Walgreens Specialty Pharmacy Program. Coverage for prescription drugs purchased at a retail pharmacy or through the mail order service is limited to a 90-day supply. Coverage for prescription drugs purchased through the Specialty Pharmacy Program is limited to a 30-day supply.
Pharmacy Benefit Manager Catalyst Rx is the pharmacy benefit manager for the prescription drug program. Catalyst Rx is responsible for:
Managing the prescription drug mail order program,
Negotiating with pharmaceutical manufacturers,
Developing and maintaining a network of participating pharmacies,
Developing a list of preferred drugs,
Processing prescription claims from participating pharmacies, and
Processing prescription claims when a participant files a paper claim.
When a prescription drug is purchased at a participating retail pharmacy, the participant is only required to pay the appropriate co-payment amount (after the applicable deductible is met) or the cost of the drug, whichever is less. There is no claim form to file. When a prescription drug is purchased at a non-participating pharmacy, the participant must file a claim with Catalyst Rx. Payment of the claim will be made based upon the Plan’s allowable charge. The participant is responsible for any amount in excess of the allowable charge, plus the applicable deductible and co-payment.
Catalyst Rx Customer Service Catalyst Rx is available 24 hours a day, 7 days a week to provide assistance to Plan participants. If a participant should experience a problem having a prescription filled or have a question regarding coverage, he may contact Catalyst Rx at 1-866-757-7839.