Prescription drug coverage is included automatically when you enroll in a Raymond James medical plan.
Under the medical plans, prescription drug costs are determined by a three-tier formulary structure:
- Generic drugs usually cost less than brand name drugs. These are reviewed by the FDA to ensure that they work the same as the brand name in dosage, safety, quality, performance, strength and usage.
- Preferred brand name drugs are on the formulary and are less expensive than using a non-preferred drug.
- Non-preferred brand name drugs are not on the formulary. These may cost you more, even if they are recommended by your doctor.
If you are enrolled in either plan, you must pay the full cost of the negotiated rate in-network for prescriptions until you meet the medical deductible. Once you have met the deductible, you will pay a copay under the Plus plan or a coinsurance amount under the Base plan for prescriptions. These costs are based on a three-tier formulary.
Helping to meet your deductible
In both medical plans, the cost of prescription drugs counts toward the medical plan deductible. That means you have to pay the full cost of the prescription before you and Raymond James begin to share in the cost.
Here’s an example:
If you’re taking a $12.19 prescription for Doxepin HcI and you haven’t met the deductible, you pay $12.19. That’s really important, especially for you and covered dependents managing more serious conditions, where the drug might cost much more. See the following resources for saving on prescription drugs:
- Use Health4Me or myuhc.com to locate pharmacies in area and review costs and alternative options.
- Visit goodrx.com to see if there are manufacture rebates or discount coupons for your Rx.
- Check with your provider to see if there is an over-the-counter equivalent you can take instead of a brand name or generic Rx.
If you are prescribed a specialty medication, it must be filled using BriovaRx.
BriovaRx is a mail subscription pharmacy. See details on RJnet.
Mandatory Generics Program
If you or your doctor requests a brand name medication when a generic equivalent is available, you'll be responsible for paying:
- The brand name medication copay
- The difference between the cost of the brand name drug and the generic medication
See RJnet for more information about covered and excluded drugs on the formulary.
Affordable Care Act (ACA) regulation
The United States Preventive Services Task Force (USPSTF) recommends low- to moderate-dose intensity statins be provided for primary prevention of cardiovascular disease (CVD) in individuals at high risk. As a result, the Affordable Care Act (ACA) requires statins to be covered at $0 cost-share for members who meet specific coverage criteria:
- Being age 40-75 and
- Having one or more cardiovascular risk factors such as dyslipidemia, diabetes, hypertension or smoking, and
- Having a calculated 10-year risk of a cardiovascular event of 10% or greater. This will require universal lipid screening for this age group.
Since the ACA allows medical management, not all statins will be covered at zero cost-share. Generic lovastatin tablets will process at $0 cost share for all members ages 40-75. Other statin medications may continue to be covered at a current tier, or will adjudicate per plan benefit. A provider/member-initiated prior authorization will be required for the noted strengths of atorvastatin and simvastatin to ensure the member is using the medication for primary prevention and has the noted risk factors.
|Statins to be covered at $0 cost-share|
|No prior authorization required (ages 40-75)||Lovastatin (generic Mevacor)
|Prior authorization required to confirm risk of cardiovascular disease||Atorvastatin (generic Lipitor)
10 & 20 mg*
Simvastatin (generic Zocor)
5, 10, 20 and 40 mg*
*Only these strengths will be available for $0 cost-share.