1 Oxford s HMO products are underwritten by Oxford Health Plans (NY), Inc., Oxford Health Plans (NJ), Inc., and Oxford Health Plans (CT), Inc., and insurance products are underwritten by Oxford Health Insurance, Inc. MS Oxford Health Plans, Inc. 6315
2 Questions about your pharmacy benefit. Pharmacy Q&A
3 Brand vs. Generic 1. Who manages pharmacy benefits at Oxford? Medco Health Solutions, Inc. (Medco Health), manages prescription drug benefits (both retail and mail-order) for Oxford Members. Pharmacy Customer Service can be reached 24 hours a day, 7 days a week at (except for Thanksgiving Day and Christmas Day). You may also log on to their web site, 2. What is a brand name drug? Brand name drugs are medications that are fully tested and approved by the Food and Drug Administration (FDA). After FDA approval, the drug is patented and marketed under a name chosen by the manufacturer. This patent protection allows the manufacturer to gain exclusive marketing rights for its product. Brand name drugs generally have higher copayments than generic drugs. 3. What is a generic drug? According to the Food and Drug Administration (FDA), a generic drug is a medication that has the same active ingredients, dosage, strength, and method of administration as its brand name counterpart. Generic drugs are safe and must meet the same quality standards as brand name medications. The FDA sets quality standards and reviews all generic medications before they are marketed. The same companies that make the brand name products make many generic drugs. Generic drugs generally have lower copayments than brand name drugs. 4. What s the difference in copayments between brand and generic drugs? Your prescription drug benefit is either a two-tier or a three-tier plan. If you have a two-tier drug plan, you will have one copayment amount for brand name drugs, and a lower copayment amount for generic drugs. Members who have a three-tier prescription drug benefit have a copayment tier for preferred brand drugs, which is greater than the copayment for a generic drug, but less than the copayment for a non-preferred brand name drug. For most plans, you will pay the lowest out-of-pocket cost for generic drugs. 5. Why are some medications preferred and other medications non-preferred? Within a class of drugs, there are often several brand name drugs protected by separate patents. These drugs are approved by the FDA for use in treating a specific medical condition. These medications are evaluated based on approved indications, efficacy, clinical studies, and side effects. The pricing of these different medications can vary significantly. Certain drugs are, therefore, designated as preferred brand name drugs, which Oxford makes available at a lower cost to the Member than non-preferred brand name drugs. 6. Where can I go to find out more about prescription drugs? You can log on to and select Oxford s Drug List from the left navigation bar or click on the Medco Health link to learn more about medication pricing and coverage. You may also log on to their web site Two-tier vs Three-tier 7. What s the difference between two-tier and three-tier? Your prescription drug benefit is either a two-tier or a three-tier plan. If you have a two-tier drug plan, you will have one copayment amount for brand-name drugs, and a lower copayment amount for generic drugs. For Members with a three-tier copayment plan, lower copayments are applied to generic and preferred brand drugs, which are designated as being on the preferred drug list. This list is provided to offer Members a choice from a wide selection of preferred drugs and to help keep the cost of prescription drug benefits affordable. The copayment for preferred brand drugs is more than the copayment for a generic drug, but less than the copayment for a non-preferred brand name drug. Please check your Summary of Benefits and Prescription Drug Rider for details on your pharmacy plan and copayments.
4 Two-tier vs Three-tier (continued) Some examples of Oxford s two-tier pharmacy copayment levels. Generic Drug Copayment Level Brand Name Drug Copayment Level $5.00 $10.00 $5.00 $15.00 $7.00 $20.00 Some examples of Oxford s three-tier pharmacy copayment levels. Non-preferred Brand Drug Generic Drug Copayment Level Preferred Brand Drug Copayment Level Copayment Level $5.00 $15.00 $35.00 $7.00 $20.00 $50.00 $10.00 $25.00 $50.00 (Please note: Copayment levels will vary depending on the pharmacy benefits selected by the employer group.) Precertification 8. Why does Oxford require precertification or prior approval on certain drugs? Based on plan design, selected high-risk or high-cost medications may require precertification by Oxford to be eligible for coverage. Precertification, also known as prior authorization, requires that your physician formally submit a request to and receive approval from Medco Health in order to receive coverage for a prescription for certain medications. Precertification criteria have been established by the Pharmacy and Therapeutics Committee with input from plan physicians and in consideration of the current medical literature. The goal is to encourage drug therapy that is appropriate and economical for our Members. 9. Which medications require precertification? For most Members with pharmacy benefit coverage through Oxford, the medications on the following list (including their generic, if available) generally require precertification through Medco Health, based on Oxford s coverage criteria. For more information on which medications require precertification, visit our web site at oxfordhealth.com or contact Oxford s Pharmacy Customer Service at Acne drugs Avita 2 Differin 2 Retin A 2 Allergic rhinitis/asthma Singulair Arthritis drugs Bextra Celebrex Enbrel Humira Kineret Vioxx Anabolic Steroids/Androgens Anadrol-50 Androderm patches Androgel Android Deca Durabolin Delatestryl Depo Testosterone Halotestin Methyltestosterone Oxandrin Testim Testoderm Testosterone Testred Winstrol CNS Stimulants Adderall 1 Concerta 1 Dexedrine 1 Desoxyn 1 Dextrostat 1 Erectile Dysfunction Drugs Caverject Edex Muse Viagra Proton Pump Inhibitors Aciphex Nexium Prevacid Prilosec Protonix Misc. drugs Forteo Nutritional therapies 3 Serostim Vitamin D preparations Misc. Gastrointestinal drugs Lotronex Zelnorm Specialized OB/GYN drugs Lupron (3.75 mg & mg) 1 Applies only to Members 19 years of age or older. 2 Applies only to Members 40 years of age or older. 3 For coverage information, Members should contact Oxford Customer Service at the number on their ID card. Please note: Precertification requirements may vary, depending on the Member s benefit. This list is subject to change without notice. For the most up-to-date information, please call Pharmacy Customer Service at
5 10. How do I receive coverage for a prescription which requires precertification? In order to receive in-network coverage for a prescription for certain medications, your physician must formally submit a request to and receive approval from Medco Health. To obtain precertification, your physician can call Medco Health directly at , Monday through Friday from 8:00 AM to 9:00 PM (eastern standard time). 11. Why does Oxford limit the quantity covered at one time for certain medications? For certain medications, and based on plan design, a limitation in the quantity covered at one time may be in place, often reflecting the maximum FDA-recommended dosage for a medication or use of the most efficient dosage strength for the fully prescribed daily dose. In these situations, an electronic message specifying quantity limit will be sent to the pharmacist instructing that the prescription be reviewed with the prescribing physician. In all cases, the goal is to encourage medically appropriate and economic use of medications for our Members. Pharmacy/Prescriptions 12. Where can I get my prescriptions filled? Medco Health has a comprehensive retail pharmacy network of nearly 50,000 locations nationwide, including approximately 6,000 locations in Oxford s service area with major chains including CVS, Duane Reade, Eckerd, Genovese, The Medicine Shoppe, Stop & Shop and Walgreens. Prescriptions can be filled at any of the area pharmacies that participate with Medco Health you are not limited to a single location. 13. How do I locate a participating pharmacy? To locate a participating retail pharmacy nearest you, please call Pharmacy Customer Service at and use the automated pharmacy locator. In addition, customers can use the online pharmacy locator at 14. Can I get my 90-day supply at the local pharmacy? For most Members, the covered supply of any prescription drug is limited to the amount normally prescribed by the physician, but not to exceed a 30-day supply. In accordance with New Jersey law, however, New Jersey Members may be able to obtain up to a 90-day supply of certain medications. Please check your Summary of Benefits and Prescription Drug Rider for details on your pharmacy plan terms of coverage and copayments. 15. When can I refill my prescription? Refills of prescription drugs will only be covered as ordered by the physician and only after 3 4 the original prescription has been used. 16. What if I lose my prescription? Oxford will not cover refills of prescriptions that are lost, stolen or misused by the Member, even is such refills are ordered by a physician.
6 Formulary 17. What s a formulary and what does it mean to my coverage? The formulary is developed by the Oxford Health Plans, Inc. Pharmacy and Therapeutics Committee (P&T Committee). This committee, composed of physicians from various medical specialties and pharmacists, reviews the medications in all therapeutic categories based on Members medical needs and out-of-pocket costs. Oxford s P&T Committee will regularly review new and existing medications so that the formulary remains responsive to the needs of our Members and providers. The contents of the formulary represent outpatient prescription drugs that may be covered for Members under their Oxford Health Plans Drug Benefit. It is important to note that the listing of a drug does not guarantee coverage, as certain products are excluded due to benefit plan design limitations specific to Members individual or group benefits. The formulary only applies to outpatient prescription medications dispensed by participating pharmacies. The formulary does not apply to inpatient medications or to medications obtained from and/or administered by a physician. Please check your Summary of Benefits and Prescription Drug Rider for details on your pharmacy plan terms of coverage and copayments. Prenatal Vitamins/Deductibles/Affordability 18. If I go to an out-of-network doctor, can he/she still write me a prescription and have it be covered in- network? Coverage for prescription drugs will be provided if the prescribed drugs are approved by the FDA, ordered by a physician (who is licensed to prescribe prescription drugs), and is dispensed by a participating network pharmacy. 19. Are prenatal vitamins covered? Coverage for certain drugs may be excluded due to benefit plan design limitations that are specific to Members individual or group benefits. Prenatal vitamins may not be covered under all pharmacy benefits. Please refer to your Prescription Drug Rider for coverage details. 20. What is a pharmacy deductible and how does it work? A pharmacy deductible is the amount each Family Member must pay in prescription costs each year, out of pocket, before becoming eligible for pharmacy coverage by Oxford. Not every pharmacy benefit will include a deductible. In addition, there are several types of deductible options available in certain markets. To determine if a pharmacy deductible is included in a Member s policy and the specific details of the coverage, check your Summary of Benefits. Or contact Pharmacy Customer Service at for additional information. Once a Member has met any applicable deductible they will be responsible for the applicable cost share in the form of a copayment or coinsurance. For example: A Member has $25 remaining on his/her deductible and a prescription copayment of $20. He/she fills a $75 brand name prescription and pays $45 ($25 from the remaining deductible plus the $20 copayment). 21. How is Oxford trying to keep healthcare costs affordable for its Members? Due to the escalation in the overall cost of drugs, Oxford has modified its copayment options for those Members who have prescription benefits through their employers. Oxford has introduced, and will continue to promote, the three-tier pharmacy benefit. Oxford's three-tier prescription drug benefit provides Members with the option of paying the lowest copayment for generic drugs, a higher copayment for preferred brand drugs, and the highest copayment for non-preferred brand name drugs. Along with benefit changes, Oxford will continue to implement clinical pharmacy management programs that not only improve quality of care but also better manage costs by lowering drug/hospital costs by reducing unnecessary drug cost and wastage and reducing exposure to medical costs due to adverse drug reactions.
7 Mail Order 22. Can I order prescriptions by mail? In order to get prescriptions filled through Oxford s mail-order pharmacy, your employer must purchase pharmacy coverage that includes mail-order coverage. Prescriptions can be ordered online, by telephone, or by mail. If you have mail order pharmacy coverage, visit for specific instructions on filling prescriptions by mail. It is important to note that only certain maintenance medications can be filled through the mail order benefit. 23. Which medications are available through the mail-order benefit? Oxford offers Members the ability to obtain a 90-day supply of certain medications, which are approved by the Food and Drug Administration (FDA) for use in the treatment of the following medical conditions, through the mail-order benefit. Some plans may include additional medicines. Please refer to your plan documents. Benign Prostatic Hyperplasia Chronic Cardiovascular Disorders Chronic Hyperlipidemia Chronic Obstructive Pulmonary Disease Clotting Disorders Colitis Diabetes Estrogen Therapy Glaucoma Gout Hypertension Osteoporosis Seizure Disorders Thyroid Disease 24. Are prescription allergy medications available through the mail-order program? Non-sedating antihistamines, nasal steroids, and other medications used in the treatment of allergies are not available through Oxford s mail-order service Medco Health Home Delivery Pharmacy Service. These medications are only available through a Medco Health participating retail pharmacy. It is important to note that prescription strength non-sedating antihistamines are now available without a prescription (e.g. Alavert). Some plans may include additional medicines. Please refer to your plan documents.
8 Vacation 25. What is a pharmacy vacation override? A pharmacy vacation override allows Oxford Members with a pharmacy benefit to obtain an additional onemonth supply beyond the normal dispensing/quantity limitation of a prescription, in the event that (s)he will be out of the service area. Members must obtain the additional supply from a Medco Health participating pharmacy and are responsible for any applicable copayments. Vacation overrides cannot be offered for lost, stolen, or misused drugs. There are NO exceptions to this policy. Eligible Members are allowed a one-month vacation override, two times per year per medication. The Member must have a valid prescription with refills in order to obtain the additional one-month supply. 26. How do I get an additional supply of my prescription medications if I am going on vacation? Commercial and Medicare Members who are requesting a one-month pharmacy vacation override should use one of the following options: Have their pharmacist call or Contact Pharmacy Customer Service directly at to request a one-month vacation override. An override will be issued at the time of the call, provided the Member meets the eligibility criteria. 27. What if I need more than a one-month additional supply? If a Member requires more than a one-month vacation override, then the Member is required to pay out of pocket for the additional supply of medication and submit the following documents to Oxford for reimbursement. The original prescription receipt. A cash register receipt is not acceptable. A letter indicating the necessity of the additional supply. A completed Prescription Drug Reimbursement Form. If eligible, the Member will be reimbursed minus any applicable copayment(s).
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