UIGRADCare Health Plans Outpatient
Prescription Drug Coverage
Outpatient prescription drugs are covered under the UIGRADCare health plan through a prescription drug plan called Blue Rx Preferred. Blue Rx Preferred is a network of pharmacies. To fill a prescripton, your pharmacist will need your prescription and your Wellmark Blue Cross and Blue Shield of Iowa identification (ID) card.
The UIGRADCare plan covers outpatient drugs routinely prescribed for common acute and chronic conditions. Some complex medical conditions may require the use of special injectable medications. In these instances, arrangements have been made so that coverage will occur under the medical portion of your health plan rather than through the Prescription Drug Plan.
The UIGRADCare co-payment is $7 or 25%, whichever is greater.
The pharmacy is responsible for submitting your prescription claims electronically.
You can search the Wellmark Drug List by visiting Wellmark's web site at: http://www.wellmark.com/. There is a $1,100 per year out-of-pocket maximum (OPM) for individuals and $1,700 for families for prescription drugs. Once the OPM has been met, the plan pays 100% of the expenses incurred for drugs during the rest of the calendar year. The OPM amount for prescription drugs is separate from the medical OPM.
To find out the amount you have accumulated towards your out-of-pocket maximum, or if you wish to have a report of your prescription drug usage, you can request this information by contacting Blue Rx Preferred at the telephone number listed on your identification card.
You are encouraged to receive all of your prescription drugs from one Blue Rx Preferred pharmacy. If you need to change pharmacies, request a family prescription profile from your current pharmacy for your new Blue Rx Preferred pharmacy. This will allow your pharmacist to become acquainted with your family's medication history.
Blue Rx Preferred pharmacies are committed to providing you with high quality pharmaceutical care services that include:
- Patient drug therapy counseling and education
- Medication profile maintenance and review
- Patient drug therapy compliance assessment
- Consultation with prescribers to ensure appropriate medication use, minimization of drug interactions and adverse effects, and use of the most cost-effective drug therapies.
If you purchase a brand name drug when an FDA-approved “A”-rated generic equivalent is available, you are responsible for your co-payment or coinsurance, plus any difference between the billed charge for the brand name drug and the billed charge for the generic. This can result in you paying substantially higher costs than if you had chosen the generic drug.
If your physician feels it is important for you to have the brand name drug, they can write the prescription for the brand name drug with the direction, “Dispense as Written” on the prescription. In this situation you will not be responsible for the difference between the billed charge for the brand name drug and the billed charge for the generic drug.
The UIGRADCare health plan provides the following coverage under the Prescription Drug Plan when services are provided by a Blue Rx Preferred pharmacy:
Services Covered by the Prescription Drug Plan
- Prescription drugs (unless specifically excluded)
- Prescription prenatal vitamins
- Prescription contraceptives and devices
- Prescription smoking cessation drugs
- Prescription drugs used as part of home health care services
- Insulin
- Disposable syringes and needles for the injection of insulin
- Glucose monitoring sticks/strips
Services Not Covered by the Prescription Drug Plan
- Over-the-counter drugs that do not require a prescription
- Therapeutic devices and appliances, including hypodermic syringes, except disposable syringes and needles for the injection of insulin
- Nutritional supplements, including vitamins (except for prescription prenatal vitamins)
- Investigational drugs labeled "Caution: Limited by Federal Law to Investigational use"
- Drugs not medically necessary for the treatment or prevention of illness, injury, or other covered condition
- Drugs used for cosmetic purposes (e.g., tretinoin (Retin-A) for treatment of skin aging, minoxidil (Rogaine) for stimulation of hair growth)
- Drugs dispensed by a person authorized to prescribe drugs (e.g., physicians, dentists and advanced registered nurse practitioners.)
- Drugs obtained outside the United States
- Charges for drugs covered by Worker's Compensation laws or other federal, state, or county programs
- Weight reduction drugs
- Drugs for which prior authorization was required but not obtained
Outpatient Prescription Drugs Covered by the Medical Portion of Health Plan (subject to coinsurance requirements)
- Special injectable drugs for complex medical conditions
- Antihemophilic factors
These drugs are not covered by the Prescription Drug Plan. You will need to pay the full price if these drugs are obtained from a pharmacy. To obtain reimbursement under the medical portion of your health plan, follow the procedures for filing a claim with Blue Cross and Blue Shield of Iowa for these drugs.
Prescription Drug Plan Quantity Limits
Acute medical treatment (short term therapy)
- As prescribed, up to a maximum of a 34-day supply per prescription for acute care drugs.
Maintenance Drug Program (chronic therapy)
- As prescribed, up to a maximum of a 100-day supply per prescription for chronic drug therapy; or 100 syringes for the injection of insulin.
- Note: Only prescription drugs included on the Blue Rx Preferred maintenance drug list qualify for a 100-day supply. All other drugs are considered acute therapy and are limited to a 34-day supply. Your pharmacist can let you know how quantity limits apply to your prescription.
- Contraceptives and Estrogen Replacement Drugs as prescribed, up to a maximum of a 6-month supply per prescription.
Procedures for Obtaining Refills
A prescription refill may be obtained only after at least 75 percent of the quantity initially provided has been used. Early refills or quantities exceeding the 34-day supply may be provided in certain circumstances. To obtain an early refill or to receive authorization for a supply greater than 34 days, ask your pharmacist to contact Blue Rx Preferred at the telephone number listed on your identification card.
Procedures for Obtaining Prescriptions and Filing Claims Out of Network
In the event that you need to have a prescription filled out of network by a pharmacy other than your regular Blue Rx Preferred pharmacy, either in Iowa or out-of-state, the following options are available for obtaining coverage for your prescriptions:
- Ask the pharmacist if the pharmacy is a member of Blue Rx Preferred. There are Blue Rx Preferred pharmacies throughout the area. If the pharmacy belongs to Blue Rx Preferred, your prescription will be handled in the same manner as by your regular pharmacy. You will only have to pay $7 or 25%, whichever is greater. Your prescription claim will be submitted electronically by the pharmacy.
- If the pharmacy is not a Blue Rx Preferred
member, you must pay in full at the time you fill your prescription.
You must submit a claim form to Catalyst Rx, in order to obtain
reimbursement for the balance of the charge above your co-payment
amount. You may obtain a claim form from The University of Iowa
Benefits Office or through the University
Benefits website. The completed claim form should be returned
to:
- Catalyst Rx
Claims Department
P.O. Box 1069
Rockville, MD 20849-1069
- Catalyst Rx
- Nonparticipating pharmacies do not agree to accept payment arrangements. This means that you may not be reimbursed for the full amount you paid if you go to a nonparticipating pharmacy. You are responsible for any difference between the billed charge and the maximum allowable fee.
Blue Rx Preferred Pharmacies
Blue Rx Preferred Pharmacies are located nationwide. For participating pharmacies, please call 1-800-600-8065 or go to www.wellmark.com.
Mail Order Prescription Program
Registering for the Program
You must register as a Walgreens Mail Service User in order to fill prescriptions by mail order. You may register by:
- Completing a registration and prescription order form at www.wellmark.com; or
- Calling Walgreens Mail Service at 866-611-5961.
Initial Order
Orders may be placed by mail or faxed from your physician’s office. Mail your original prescriptions, payment, and the completed registration and prescription order form to:
Walgreens Mail Service
P.O. Box 29061
Phoenix, AZ 85038-9061
For orders placed by mail, you may pay by credit card, check, or money order. Do not send cash.
Or ask your physician to fax your prescription to Walgreens Mail Service at 800-332-9581. Physician fax order forms are available at www.wellmark.com or by calling the Customer Service number on your ID card. Faxed prescriptions are only valid when faxed from your physician’s office.
If you place your order by fax, you must pay by credit card.
Prescriptions are typically delivered within 10 to 14 days after the order is received.
Refill Orders
You may place refill orders online at www.wellmark.com, by calling 800-797-3345, or by mailing a completed refill request slip to:
Walgreens Mail Service
P.O. Box 29061
Phoenix, AZ 85038-9061
Each time you submit a prescription order through the mail order program, you will receive a reorder form and envelope and a refill request slip specifying when you can request a refill and the number of refills remaining (if any).