Scott & White Health Plan

Pharmacy Prescriptions

Prescription Drug Benefit

SWHP offers TRS-ActiveCare enrollees a prescription drug rider. You simply pay a co-payment to receive certain prescription medications. Please refer to the Health Care Evidence of Coverage for co-payment amounts and limitations. New and refill medications (34 day supply) may be dispensed by any SWHP network pharmacy provider or the SWHP Express Mail Pharmacy.

A formulary is a list of selected medications that are covered by your drug benefit. These medications are chosen by a committee composed of physicians and pharmacists. The formulary is designed to help your doctor in the selection of safe, appropriate, and cost-effective drug therapies. It is under constant review and may change as new medicines or new information on current medicines becomes available. Some medicines are not covered by your drug benefit. Examples of non-covered medicines are medicines for cosmetic purposes or weight loss, medicines available without a prescription or medicines used for experimental purposes. If your physician prescribes a medication that is not on the formulary, and is not specifically excluded from coverage, you and your physician may choose one of the following options:

• Your physician may change your prescription to a medicine listed on the formulary. This will generally result in a lower co-payment for the medicine.
• You may have the prescription filled and you will be responsible for a portion or total cost of the medication according to your Health Care Evidence of Coverage.

There are occasionally special situations in which the SWHP will cover medications not included on the formulary. The SWHP Medical Director reviews the individual case and may approve an exception. To initiate this review, your provider will need to send a request to SWHP.

Generic Drugs

SWHP only covers the generic equivalent drug if available and if the generic drug has received an "A" rating by the Food and Drug Administration. This rating indicates the generic product performs equally to the brand name. If available, a generic drug is dispensed and you are charged the generic co-payment. If your doctor chooses a brand name medicine when a generic equivalent is available, you may be charged a higher co-payment.

Maintenance Drugs

The Maintenance Drug List is made up of routinely prescribed medications for certain chronic illnesses that affect a large number of SWHP enrollees. Examples of medications on the Maintenance Drug List are: medications for blood pressure, diabetes, seizure medications, hormone therapy for women, and thyroid medications. Drugs that do not qualify for maintenance drugs are long-term drugs prescribed to a small segment of enrollees or the drug's safety is a potential concern.

Your drug benefit may allow a larger supply of medicine for a specified co-payment. There are generally five conditions that must be met. To receive maintenance quantities, the medication:

• Must be dispensed by a SWHP-owned pharmacy or SWHP Express Mail Pharmacy
• Must be included on the Maintenance Drug List
• Must be approved by your physician for a three month supply (90 days)
• Must be prescribed by a SWHP provider for at least six months
• Must be taken continuously for at least six months

If you have any questions about your prescription drug benefit, please contact a Customer Service Advocate at a SWHP office near you.