Prescription Benefits
There are many unique ways that prescription benefits are covered. Each plan is different. Different drugs have different coverage levels and some may have specific coverage requirements.
- You will find your general prescription benefits under the Prescription Drugs and Pharmacy Services section of your benefit document.
- You will find your Specialty Drug benefits under the Specialty Drug Prescription Program section of your benefit document.
- You may also have Mail Order Pharmacy Benefits as a part of your plan. You will find your Mail Order Pharmacy benefits under the Mail Order Pharmacy Program section of your benefit document.
- Below are some of the unique coverage requirements that some drugs may require.
Visit Medica's Pharmacy page to find out if your drug has a unique requirement. - For certain drugs, Step Therapy is required in order for you to receive your best benefit. Step Therapy is a process where the patient starts out using a more established drug (typically a generic) as the first step of treatment. If that drug is not effective, the next step is to try the newer or alternative drug treatment in that condition.
- A Prior Authorization ensures appropriate drug use for conditions where the drug is proven effective, and deters using the drug for conditions where its use is unproven or experimental. Prior authorization is a process that a physician follows to request coverage from Medica for a particular drug (if approved, Medica will provide coverage). These are designated by a "PA" on the list of preferred drugs.
- A Quantity Limit is the maximum quantity allowed per prescription over a specific time period. Some medications are subject to quantity limits based on the pharmaceutical maker's packaging, FDA-approved labeling, or adopted clinical guildelines. These are designated by a "QL" on the list of preferred drugs
- Before coverage for a refill of a medication will be approved, you need to use up 75% of your medication from the previous fill.
- If you have any further questions regarding your benefits, please contact Customer Service at the number on the back of your ID card.
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