PRESCRIPTIONS
PLAN ADMINISTRATOR – MEDCO
Medco Health Solutions, Inc., (Medco) has functioned as the pharmacy benefit manager for the State of Delaware Group Health Insurance Plan since July 1, 2006.
Member Services 1-800-939-2142
Available 24 hours a day, 7 days a week, 363 days a year
(Closed Thanksgiving and Christmas Days)
Pharmacists available around the clock
Medco Website (www.medco.com)
- Register at medco.com for special services!
When you register at medco.com®, you have access to special services from Medco.
With your Medco member ID number and a recent prescription number on hand, go to www.medco.com® and create your Medco username (email address) and password.
- Online safety alerts: Whether you get medication at a retail pharmacy or by mail, if you take medications regularly, this service provides you with personalized alert messages to notify you if:
- You're running low on a medication
- You miss a prescription refill
- You may be missing a medication that could benefit your health and you need to discuss it with your doctor
- Health Resource Center (Diabetes, Women's Health, Oncology and more)
- MEDCO SMARTPHONE APP (click for information)
- Medco Health Store® for Over-The-Counter Medications
Coverage Management Programs
As part of the 2012 DelaWELL Tobacco Cessation Program, copays for prescription tobacco cessation medications will be waived beginning July 1, 2012 when purchased at participating retail pharmacies or the Medco Pharmacy (mail order). These medications include Nicotrol NS, Nicotrol Inhaler, bupropion HCI (Zyban) and Chantix.
The following coverage management programs will be effective July 1, 2012: Incivek, Victrelis (Hepatitis C Medications) and Simponi, Cimza (Rheumatoid Arthritis Medications). You will be contacted by Medco if this program impacts your current prescription drug usage.
Additional information regarding prior authorizations and the Step Therapy Program is available under the heading "Programs" below.Introduction to Medco
- Picture of Identification Card
- Welcome Kit
- Letter of Introduction
- Your Pharmacy Benefit Program Handbook
- Identification Cards --- MUST be used to obtain prescription at retail pharmacy
- Medco by Mail Order form to request refills or have new prescriptions filled
- Health, Allergy & Medication Questionnaire form for each participant (not available to place on site at this time)
(some families may receive in a separate mailing). Please contact Member Services to receive replacement or additional copies.
Prescription Copays
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Cost Savings With 90-Day Prescriptions: You’ll pay only 2 times your 30-day retail co-payment if you order up to a 90-day supply of covered medication at a 90-day participating pharmacy or through Medco’s mail order service, Medco Pharmacy. Please note: (1) You are required to fill certain long-term medications using 90-day fills, or you will pay a penalty copay (please see “Maintenance Medication Program” below). (2) Some medications, such as certain controlled substances or medications that are prepackaged by the manufacturer, are not available in a 90-day supply.
Preventive Medications at Zero Copay for CDH Gold Plan Members
Coordination of Benefits/Direct Claims for Prescriptions
- Coordination of Benefits/Direct Claim form to request secondary coverage or request reimbursement
- How Direct Claims and Secondary Prescription Claims Pay
Pharmacies
- Retail Pharmacies - You may have your prescriptions filled at any pharmacy that participates in Medco's network. If the pharmacy is also a 90-day participating pharmacy, you may fill maintenance or other prescriptions for up to a 90-day supply. If the pharmacy is not a 90-day participating pharmacy, you can fill prescriptions for up to a 60 day supply.
- Medco Pharmacy (mail order prescription service). To have a new prescription filled through the Medco Pharmacy, you may:
- Mail the prescription, a completed mail-order form, and payment to Medco Pharmacy.
- Ask your doctor to fax the prescription to Medco by calling 1-888-327-9791 for instructions. (Only your doctor can fax prescriptions.)
- Refills may be ordered online at www.Medco.com
- For more information, call Member Services at 1-800-939-2142.
- Specialty Pharmacy (Accredo Health)
Medco's Specialty Pharmacy - "Accredo Health"
Some health conditions require medications that are classified as "specialty medications" and are provided through Medco's Specialty Pharmacy, Accredo Health. Effective July 1, 2010, medications used to treat some forms of cancer and Multiple Sclerosis are classified and administered as specialty medications. Accredo Health's staff will reach out to physicians and members to work together in managing the member's prescription needs. Members may receive their first 30-day fill of a new specialty medication through a retail pharmacy, but must have subsequent refills of the same medication provided by Accredo Health or be personally responsible for the entire cost of the medication.
When a member receives medication through Accredo Health a nurse is assigned to each member. The member is welcome to contact the nurse to discuss his/her prescription needs and health condition.
Prescriptions are delivered directly to a member’s home with unique packaging, as necessary, to ensure safety.
Additional information on prescription services provided by Medco is available on Medco’s website
Formulary
PROGRAMS
Compound Medication Program
- Effective March 1, 2011 the preferred brand copay ($20 for a 30-day supply; $40 for a 90-day supply) became the standard copay for all compound medications.
- Effective January 1, 2012, due to Federal changes in compound medication processing and payment, reimbursement calculations for compound medications filled at a non-participating pharmacy have changed. Reimbursement is calculated as the lower of: (1) the total charge less the preferred brand copay; or (2) the maximum allowable cost for the total ingredients, less the preferred brand copay. For example, if the non-participating compound pharmacy charge totals $80.00, and the maximum allowable cost for the State of Delaware is $62.00, the member's reimbursement will be $42.00 ($62.00 less the $20.00 copay).
Maintenance Medication Program
- Information on Maintenance Medication Program
- Quick Reference Guide of Savings
- Examples of Maintenance Medications Effective 7-1-2009 – Call Medco’s Member Services at 1-800-939-2142 for a complete list.
- Medications added to program effective September 1, 2010
Coverage Review Program
The State of Delaware has developed comprehensive prescription drug programs to provide members with effective medications at a reasonable cost. Some programs limit the use of certain medications, and for each of these programs there is a Coverage Review Process available. Please select this heading for an overview of the Coverage Review Program, and select any of the headings below for details and lists of medications.
Choice Program...Generic vs. Brand Medications
Traditional Prior Authorization Program
Smart Prior Authorization and Step Therapy
Authorization for Additional Quantity of Medication
Medicare Part B
Some medications (as well as diabetic medications and supplies described under "Diabetic Program") are covered through Medicare Part B for those enrolled in Medicare Part B. Prescriptions for these medications and supplies will first be processed through Medicare Part B, and pay at 80%, with the member responsible for the remaining 20% at the time of purchase. Reimbursement of the 20% may be obtained by submitting a Coordination of Benefits/Direct Claim Form, with receipts, to Medco
Medco’s Coordination of Benefits/Direct Claim Form may be found at the following website or requested by calling Medco’s Customer Services at 1-800-939-2142. The completed form with receipts should be mailed to the address provided on the form.
http://ben.omb.delaware.gov/script/documents/medco/coord_of_benefits_direct_claim_form.pdf
Questions about specific medications and supplies covered through Medicare Part B may be answered by calling Medco’s Member Services at 1-800-939-2142.
Medicare Part D
