Prescription Drug Benefits
The Catalyst Rx pharmacy benefit program is available to you and your eligible family members only if your Group has purchased a Prescription Drug Rider. The following is a summary of the pharmacy benefits you can receive.
Your prescription drug benefit covers all Medically Necessary drugs that meet the following requirements:
Medications requiring Pre-authorization:
- The drug is prescribed by a licensed physician.
- The prescription medication is approved by the Food and Drug Administration (FDA).
- The prescription drug is used outside of the hospital. The prescription must be issued by a Participating Provider and filled at a Participating Pharmacy, except in an emergency or where otherwise authorized by us.
- Non-prescription items that are covered include: diabetic supplies such as urine/blood testing strips, syringes, injection aids.
- Atlantis will also pay for Medically Necessary enteral formulas prescribed by your Primary Care Provider (PCP) or other Participating Provider legally authorized to prescribe under Title VIII of the Education Law. Such written order must state that the enteral formula is Medically Necessary and has been proven effective as a disease-specific treatment regimen for those individuals who are or will become malnourished or suffer from disorders, which if left untreated, cause chronic disability, mental retardation or death.
- We will also provide coverage for modified solid food products that are low protein, or which contain modified protein, which are Medically Necessary for the treatment of certain inherited diseases of amino acid and organic acid metabolism.
Certain drugs undergo medical necessity review before they can be dispensed. These reviews are done for quality control and safety to ensure that you receive adequate supervision from the provider who prescribes them. The list of drugs that need pre-authorization is updated regularly by the plan.
|List of medications requiring authorization
||Nexium (members must try 4 weeks
of Prilosec OTC first)
||Prevacid (members must try 4 weeks
of Prilosec OTC first)
|Intron A, Referon-A
| All Chemotherapy drugs and/or injectables need to be pre-authorized.
|Please note: Any prescription costing more than $200 is routinely reviewed by the Plan when the member brings it to the pharmacy. Quantity limits may apply to some of the above medications.
To obtain pre-authorization, please call the Atlantis UM department at 1-800-270-9072 Monday through Friday from 9 am to 5 pm. Physicians prescribing the medication will be asked to submit information justifying medical necessity including history of therapeutic failures of other drugs used for the condition. All pertinent clinical information should be faxed to 212-747-8375 for the Medical Director's review. The provider and the member will be notified of the determination upon receipt of all necessary information required to render a medical necessity determination.
Exclusions and Limitations. The Plan will not pay for the following:
Non-FDA approved drugs except that we will pay for a prescription drug that is approved by the FDA for treatment of cancer when the drug is prescribed for a different type of cancer than the type for which FDA approval was obtained. However the drug must be recognized for treatment of the type of cancer for which it has been prescribed by one of these publications: AMA Drug Evaluations; American Hospital Formulary Service; U.S. Pharmacopoeia Drug Information; or a review article or editorial comment in a major peer-reviewed professional journal.
- Any prescription drug that we determine is not Medically Necessary, unless an External Appeal Agent recommends coverage.
- Experimental or investigational drugs, unless recommended by an External Appeal Agent.
- Nutritional supplements taken electively.
You may purchase drugs under these two options:
- With the retail pharmacy program you may receive up to a 34-day supply of medication (depending on your plan) from a Catalyst Rx network retail pharmacy for short-term medications.
- The mail order option allows you to obtain a 90-day supply of maintenance drugs in the following categories: anti-diabetics, anti-hypertensives, anti-hyperlipidemics, beta-blockers, calcium blockers, diuretics and thyroid medications. Please refer to your Rider for co-payment amount.
Certain medications may not be covered under the prescription drug plan or under the formulary. Please refer to your benefit plan documents for more information.
- Prescriptions obtained from retail pharmacies can be refilled when you have used 90% of the current drug supply.
- Prescriptions obtained from mail order can be refilled when you have used 70% of the current drug supply.
With your prescription drug program, there are three categories of prescription drugs: Generic, Brand-name Preferred Formulary, Brand-name Non-Preferred.
Brand-name - Preferred Formulary and Non-Preferred - The prescription drug program includes a formulary feature. The formulary is a list of preferred brand-name drugs that can meet a patient's clinical needs at a lower cost than other brand-name drugs. For purchases of preferred brand name drugs, you will pay the second highest co-payment available under the program.
The formulary was developed to maximize savings for you. Formulary medications are selected for their safety, quality, effectiveness and cost-efficiency. Formulary drugs are considered the most cost-effective brand-name drugs, and your cost for purchasing them is lower than for non-preferred brand-name drugs. For purchases of non-preferred brand name drugs, you will pay the highest co-payment available under the program.
Generic - Most generic drugs are covered under the prescription program, unless they are a specific Plan exclusion. For purchases of generic drugs, you pay the lowest co-payment available under the program. A generic drug has the same chemical compound as its brand-name counterpart and is a simple and safe alternative to help reduce prescription drug costs.
About Generic Drugs
A generic drug has the same chemical compound and is therapeutically equivalent as the brand name version. The use of generic drugs offers a safe alternative to help reduce prescription drug costs for you and your plan sponsor. The pharmacist will dispense generic substitutes whenever possible based upon availability, legal requirements and your physician's approval. Ask your health care provider to write your prescription using the generic or chemical name to ensure you'll receive a generic medication.
About Catalyst Rx Network Pharmacies:
- Plan co-payments vary according to the tier that the drug belongs to. For purchases of generic drugs, you pay the lowest co-payment available under the program.
- Cost of medications not covered under your pharmacy benefits.
Catalyst Rx has a network of retail pharmacies that provide services to our members. Many pharmacies are enrolled with us to give our members access to quality pharmacy services. To locate the network pharmacy near you, visit the Catalyst Rx web site at www.catalystrx.com or call the Catalyst Rx Customer Service Center at 1-888-341-8570. We recommend that you present your member ID card that includes necessary information every time you have a prescription filled in order to expedite your services.
Prescription Benefits Customer Service Center:
- Catalyst Rx's Customer Service Center, 1-888-341-8570, can answer many questions about your pharmacy benefit plans. Such as:
- Can I speak with a pharmacist about my prescription?
- Where can I get additional information about my benefits?
- How do I request additional ID cards?
- Is my local independent pharmacy part of the Catalyst Rx network of retail pharmacies?
Catalyst Rx Customer Service is available 24 hours a day:
For your convenience the Catalyst Rx web site, www.catalystrx.com, provides valuable information and features:
Many independent pharmacies are included in your plan. To determine if your neighborhood pharmacy belongs to the Network, call Catalyst Rx at 1-888-341-8570 or visit the Catalyst Rx website at www.catalystrx.com.
- Pharmacy Locator-a quick, easy way to locate a nearby Participating retail network pharmacy
- Searchable Formulary-valuable information on a medication you are taking
- Plan Design-your plan specific information on co-pays, plan limitations and days supply allowed
||Smith's Food & Drug
||Stop & Shop
||Stop & Shop
||Rx Plus Wegman's
About Non-participating Pharmacies
If you fill a prescription for a covered drug at a non-participating pharmacy, you must pay the retail price for the drug. Submit the claim for reimbursement to Atlantis Health Plan by filling out the reimbursement form which is available in the Members Section of our website, www.atlantishp.com. Please submit the completed reimbursement form with the official receipt from the pharmacy and send it to:
Attn: Health Services Department
Atlantis Health Plan
39 Broadway, Suite 1240
New York, NY 10006
Reimbursement for the drugs purchased at non-participating pharmacies will be paid minus the co-payment and will be limited to the reasonable charge for the drug.
Quality at a better price
Q. Are there any important differences between generic drugs and brand name drugs?
A. No, there are not. Generic drugs are made from the same chemical compound as their brand name counterparts. They are manufactured according to the same standards as name brand drugs and have The Food and Drug Administration's (FDA) approval for safety and effectiveness.
Q. Why do generic drugs cost less?
A. When a company develops a new drug it has a 17-year patent period, during which no other company can sell the drug. This eliminates competition and causes the price to stay high. During this 17-year period, the company is able to recover its costs for research and development.
Q. What happens after the 17-year period?
A. Many physicians continue to prescribe the drug by its brand name because of their familiarity, thereby keeping the brand price high. Likewise, the competition between companies offering the generic version keeps the generic price low. Unlike brand name drugs, generic drugs are not advertised which helps keep the price down.
Q. What does this mean to you and your employer or organization?
A. By asking your physician to prescribe a generic drug, you get a quality medication at a fraction of the brand name price.
Q. Do companies test generic drugs?
A. Yes, the FDA requires testing by generic manufacturers to prove their drugs will give the same results as the brand name drugs.
Q. Does the FDA monitor the quality of generic drugs as closely as brand name drugs?
A. Yes. Whether they are brand name products or generic versions, all approved drugs must meet the same FDA standards of quality. All manufacturers are subject to periodic inspection. All must follow the FDA's Good Manufacturing Practice Regulations. The FDA periodically collects samples of all drug products, both generic and brand name, from manufacturers and from the marketplace to be tested in the agency's laboratories for purity and strength. When Express Pharmacy Services fills your prescriptions with the generic version of the drug your doctor prescribed, you can be assured that it is of the highest quality available.
Q. Do shape and color affect generic drug performance?
A. No, you can be assured the difference in shape or color has no effect on the way the drug works. Medications have unique codings for ease in identification.
Q. Is there a generic version available to fill my prescription?
A. Ask your pharmacist for more information. Chances are a lower-priced, generic version of the drug your doctor prescribed is readily available. The FDA has now approved over 8,000 generic versions of a wide variety of drugs.
Q. What are some common brand names that are available as generics?
A. BRAND GENERIC