At participating pharmacies, simply present your prescription drug ID card to the pharmacist. Your eligibility for benefits will be confirmed via a computerized system. The pharmacist will tell you the amount that you are responsible for paying. You do not have to file a claim form for prescriptions filled at a participating pharmacy.
To find a participating pharmacy nearest to you, call your toll-free member services number on the back of your ID card and use the voice activated pharmacy locator system or visit the pharmacy locator on-line on the Wellmark website.
If you use a non-participating pharmacy, you must submit a completed claim form to the Pharmacy Benefit Manager (PBM). The prescription receipt must be attached to the form. To obtain claim forms, call member services. You are responsible for 100% of the price of the prescription at the time of purchase. You will be reimbursed within twenty-one days of your claim form being received. Reimbursement will be in the amount that you would have paid to a participating pharmacy, less your copayment.
Analysis and Reporting
Prescription information is used by the PBM and affiliates to administer your health benefit drug programs. The PBM also uses the information and prescription data gathered from claims submitted nationwide for reporting and analysis without identifying individual patients.
A special feature of your prescription drug plan is prior approval. Payment of a drug that is not normally covered by your plan can be requested by getting prior approval and if it is part of a specific treatment plan and medically necessary. Your practitioner should request prior approval by providing the reason the drug should be covered and the length of time. If your medication is not approved for coverage under your plan, you will be responsible for paying the full cost of the drug.
Preferred Prescription Formulary
Your prescription drug program includes a voluntary-formulary feature. A formulary is a list of commonly prescribed medications that have been selected based upon their clinical effectiveness and opportunities for savings. By asking your doctor to prescribe formulary medications, you can help control rising health care costs while maintaining high quality care. Use of a formulary drug is voluntary. There is no financial penalty if your physician does not prescribe a formulary drug.
The brand-name is the name under which a product is advertised and sold. Generic-equivalent medications contain the same active ingredients and are subject to the same rigid FDA standards for quality, strength, and purity as their brand-name counterparts. Generally generic drugs cost less than a brand-name drug. You should ask your doctor to prescribe generic drugs whenever appropriate.
If you select a brand-name drug when there is a generic-equivalent available, you will be responsible for the difference between the brand-name cost and generic drug cost.
Wellmark offers the tools you may need to manage and improve your health through the internet. Browse through the brochures, safety tips, answers to most common medication questions, or just keep up with timely health issues.
Drug Utilization Review
Under this program, when your prescriptions are filled through participating retail pharmacies, they are reviewed for any potential drug interactions based upon your personal medication profile. This is especially important if you take many different medications or see more than one physician. If there is a question about your prescription, your pharmacist may contact your physician before dispensing the medication.