Tier 1 Drugs
Generic drugs
Tier 2 Drugs
Name-brand formulary drugs
Tier 3 Drugs
Non-formulary drugs
Tier 4 Drugs
Name-brand, non-formulary drugs
The UIChoice plan uses the BlueRX Complete formulary list. In addition, you may visit the Wellmark drug list to review which tier your specific medications fall under on the list.
- Drugs available as over-the-counter medicines without a prescription are not covered under this plan.
- Participating pharmacies are responsible for submitting your prescription claims electronically.
Specialty Pharmacy Requirement
UIChoice members are required to use the UI Health Care Specialty Pharmacy for all their specialty drug needs.
UI Health Care Specialty Pharmacy has a personalized approach to assisting patients with specialty medication needs. This has resulted in above-average medication adherence, leading to higher patient satisfaction, avoidance of unwanted drug interactions, fewer hospitalizations, and better outcomes. UI Specialty Pharmacy also offers 24-hour pharmacy availability by phone and personalized assistance to patients in locating potential cost savings for specialty medications.
Find more information about the UI Health Care Specialty Pharmacy.
If you do not take specialty drugs, you will not need to do anything further. You do not need to transfer your prescriptions to UIHC pharmacies.
Specialty Pharmacy FAQ's
Medications that are high-cost injectable, infused, oral, or inhaled drugs for the ongoing treatment of a chronic condition. These drugs generally require close supervision and monitoring of the patient's drug therapy. Specialty drugs may be categorized within tiers on the formulary or as drugs covered under your medical benefit.
These drugs would treat conditions such as cancer, HIV/AIDS, Huntington disease, infertility, inflammatory bowel disease, liver diseases, including Hepatitis C, MS, organ transplants, cystic fibrosis, endocrine disorders, rheumatic diseases, skin disorders.
You can visit the BlueRx Complete formulary list, which applies to the UIChoice prescription coverage and look for the name of the drug you are taking for treatment.
A formulary drug list is a list of drugs covered under your pharmacy benefit and developed to guide physicians, pharmacists, healthcare professionals, and members in selecting cost-effective drug therapy.
The medications required to be filled by the UIHC Specialty Pharmacy are those listed as specialty drugs in the Formulary Drug List. UIChoice uses the Blue Rx Complete 3 Tier formulary.
Those drugs listed as SP-P and SP-NP would be specialty drugs required to be filled by the UIHC Specialty Pharmacy beginning 01/01/2019.
A small group of medications are covered under the medical portion of your UIChoice benefits rather than the pharmacy portion. These are labeled as "SP-M" on the BlueRx Complete Formulary. To help you determine what to do, the following rules are helpful:
- If you currently receive or will receive your "SP-M" medication at your doctor's appointment or an infusion center, you will not have to make any changes.
- If you give or will give your (SP-M) medication to yourself without any assistance, it will need to be filled through UIHC Specialty Pharmacy.
If you have any questions, please reach out to the UIHC Specialty Pharmacy (319-384-6909) for assistance.
If you are taking specialty medications, you can choose any UIHC locations within the hospital to pick up your prescription or have it mailed to your home.
UI Health Care pharmacy locations include:
- General Hospital
- Discharge Pharmacy
- Clinical Cancer Center
- Pomerantz Level 2 or Pomerantz Lower Level
- Iowa River Landing (IRL) Pharmacy
- River Crossing Pharmacy, located in Riverside, IA
Pharmacy Out-of-Pocket Maximum
The OPM expense provision for prescription drugs is separate from the medical OPM. The insured is responsible for paying coinsurance on prescriptions (as described above) up to $1,600 for individuals or $3,200 for the family in prescription drug costs. Once the OPM has been met, the plan pays 100% of covered expenses incurred for drugs for the rest of the calendar year.
Suppose you purchase a brand name drug when an FDA-approved “A”-rated generic equivalent is available. In that case, you are responsible for your 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 vital for you to have the brand-name drug, they can prescribe it with “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.
There are instructions on the Wellmark website on how to Request a Waiver of Brand if necessary.
Certain drugs are limited per month, benefit period, and lifetime by drug-specific quantity limitations, step therapy requirements, or prior authorization. The limitations are determined by Wellmark based on medical necessity. Visit the Wellmark website or check with your pharmacist or physician for a list of drugs subject to limitations.
Have a Question?
ABOUT OUR SITE:
The information presented on our website describes only the highlights of the plans and does not constitute official plan documents. Additional terms and conditions may apply. If there are any discrepancies between the information contained herein and the official plan documents, the plan documents will govern. For more detailed information, you may contact Wellmark Blue Cross/Blue Shield at the toll-free number 800-524-9242 (TTY: 888-781-4262), Monday through Friday, from 7:30 a.m. to 5:00 p.m. (Central Time). For more efficient service, please have your member ID number handy - you can find it on the front of your card.