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Health Alliance Pharmacy Benefits
The Health Alliance Pharmacy Department works hard to ensure our members
receive the most effective and affordable drugs on the market. If you have
questions, please contact the Pharmacy Department at 1-800-851-3379, extension
8078, Monday through Friday, 8 a.m. to 5 p.m.
Please note: Not all Health Alliance plans include prescription
coverage. Pharmacy benefits also vary depending on plan type.
Contact the Pharmacy Department or submit
a request
for Review of Coverage online to verify eligibility for any
of the following benefits or programs.
The Foundation: Our Standard Drug List
This list includes more than 1,200 prescription drugs approved by the U.S. Food
and Drug Administration (FDA) and covered by Health Alliance. The Health
Alliance Pharmacy & Therapeutics (P&T) Committee has researched these
drugs and found them to be clinically safe and effective and placed them in our
3-tier plan (see below) to provide the best value to our members. When a new
drug is presented for inclusion in the Standard Drug List, the P&T
committee conducts formal reviews to evaluate safety, efficacy, comparison
studies, approved indications, adverse effects, contraindications, medical
outcomes, patient compliance issues and cost-effectiveness. The P&T
Committee meets regularly to review and update the list.
In addition, some drugs require preauthorization, or approval for coverage from
Health Alliance prior to filling a prescription. This system of checks and
balances makes sure new and high-cost drugs are prescribed appropriately.
View the Standard
Drug List.
View our list of
Covered Oral Contraceptives.
The Framework: Our 3–Tier plans
A 3-tier plan is like a stepladder based on effective and affordable drugs–the
higher the step (tier), the higher the copayment or coinsurance. Members will
always pay the lowest copayment for a Tier 1 drug. Tier 2 drug copayments are
slightly higher. Members pay the highest copayment for Tier 3 drugs. The 3-tier
system helps manage costs, but provides flexibility and some coverage for
members who choose a higher tier product. This system of cost sharing also
ensures that Health Alliance can continue to cover the majority of prescription
drugs.
To determine how much your copayment will be for a specific prescription, you
can consult your plan documents to see your specific details. You can also
log in as a member and select "My Drug
Benefit" from the menu on the left.
Step-therapy
Step-therapy is a tool used to control costs for certain drug categories. If
you have a new prescription for certain kinds of medication, you must first try
the most cost-effective drug in that category before another one is covered. In
most cases, the cost-effective drug will work for you, but if it doesn’t, your
physician will need to request preauthorization for another drug in the same
category. Some categories for step-therapy include proton pump inhibitors for
acid reflux, antihistamines and certain kinds of antidepressants. Please
contact the Pharmacy Department for additional information.
Our Affiliated Pharmacies
Remember, to be covered, prescriptions must be filled at an affiliated Health
Alliance Pharmacy. Following is a list of the chain drugstores affiliated with
Health Alliance. In addition to these, many independent pharmacies also
participate in our network. Please note that this list is subject to change. To
find out if a store is participating, contact the Pharmacy Department. To find
the closest pharmacy to you, click on the pharmacy below to search for
locations by zip code. Please note that this search is not available for all
affiliated pharmacies.
Convenience and Savings Programs
Mail Order
Most members with a pharmacy benefit are eligible for the Health Alliance mail
order program through Walgreens.
This is a reliable, time-saving way for members to have prescription,
maintenance drugs delivered directly to their home.
Choice 90RX
Most members with prescription drug benefits can purchase a 90-day supply of
maintenance medication from a participating retail pharmacy. As an added value,
most members will receive a discount off the regular copayments charged for a
90-day supply. Members who prefer can continue purchasing the traditional
30-day supply of medication for one copayment from their pharmacy, or they can
purchase a 90-day supply through mail order.
Following is a list of chain retail pharmacies that participate in the Choice
90RXprogram. Approximately 50 independent pharmacies also
participate. This list is subject to change; please call the Health Alliance
Pharmacy Department, for additional participating pharmacies.
| · Carle RxExpress |
· CVS |
· Hy-vee |
· Kmart |
| · Meijer |
· Target |
· Walgreens |
· Wal-Mart |
Split the Pill, Split the Bill
For some drugs, the cost is virtually the same, regardless of strength. For
example, Lipitor® 20, 40 and 80 mg pills are essentially the same
price. Therefore, splitting a higher dose pill can save money. For most members
willing to split their pills, Health Alliance will split the cost, collecting
HALF their normal copayment. Splitting certain pills is safe, easy and saves
money. To help members take advantage of this program, a free pill splitter is
included in their pharmacy benefits. Each member who presents a Health Alliance
ID card at a participating pharmacy can pick up a pill splitter, which
typically costs $2 or less.
The following drugs, taken once daily, are eligible for pill splitting:
| AbilifyTM |
citalopram |
leflunomide |
Provigil® |
Zoloft® |
| Aceon® |
clonazepam |
Levitra® |
Risperdal® |
Zyprexa® |
| Aricept® |
Cozaar® |
LexaproTM |
Seroquel® |
|
| benazepril |
Crestor® |
Lipitor® |
sertraline |
|
| BenicarTMHCT |
Diovan® |
lisinopril |
simvastatin |
|
| BenicarTM |
Diovan®HCT |
mirtazapine |
Viagra® * |
|
| Cardura® |
Keppra® |
paroxetine |
VytorinTM |
|
|
Cialis® * |
Lamictal® |
Pravachol® |
Zocor® |
|
| * maximum dose limitation applies. |
First Month Free
To encourage long-term use of cost-effective Tier 1 drugs, Health Alliance
offers a FREE 30-day trial of any new Tier 1 maintenance medication.
Antibiotics, pain medications or short-term/periodic medications are not
included.
Value-based Benefit
The value-based benefit (VBB) means we base what members pay for a medication
based on the value it has for keeping them healthy. Certain medications used to
treat common conditions like asthma, high cholesterol, high blood pressure and
diabetes have high value and will be available to members at a lower cost.
Below is the list of high-value medications available at a lower price:
| Drug Class |
Drug Name |
Formulary Status |
| Diabetes |
All generics |
Remain at Tier 1 |
| Lilly vials, pens and cartridges |
10% coinsurance |
| Apidra vials, pens and cartridges |
10% coinsurance |
|
Lantus vials, pens and cartridges
|
10% coinsurance
|
|
Test strips for Abbott and Roche meters
|
10% coinsurance
|
|
TZDs, Avandia, Avandamet, Avandaryl, Actos, Actosplusmet, Duetact
|
Tier 2 with maximum of $20
|
|
Januvia/Janument, Byetta and Symlin
|
Tier 2 with maximum of $20
|
|
Asthma
|
All generics, Ventolin HFA
|
Remain at Tier 1
|
|
Flovent, QVAR, Advair, Symbicort and Serevent
|
10% coinsurance
|
|
Hypertension
|
All generics
|
Remain at Tier 1
|
|
Avapro/Avalide
|
10% coinsurance
|
|
High Cholesterol
|
All generics
|
Remain at Tier 1
|
|
Crestor, Simcor, Advicor
|
10% coinsurance
|
The VBB approach also means certain other drugs that have less value may cost
more. Beginning January 1, 2009, certain medications will not be covered or
have a higher copayment. However, in all cases, there is a lower cost
alternative.
Below are the affected drugs:
| Drug Class |
Drug Name |
Formulary Status |
| Dermatology |
Benzoyl peroxide products |
Not covered—available over-the-counter |
| Retin-A Micro |
Tier 3 |
| H2 Blockers |
Tagemet, Zantac, Pepcid, Axid |
Not covered—available over-the counter |
| Leukotriene Receptor Antagonists |
Accolate, Singulair |
Tier 3, with no step-therapy required |
| Hypnotics |
Ambien CR, Lunesta, Sonata, Rozerem |
Tier 3, with step-therapy of generic Ambien required first |
| Cough and Cold |
Benzonatate |
Remains at Tier 1 |
| All other products |
Tier 3 |
Only $4 for Generic Drugs at Select Retail Pharmacies
At Wal-Mart and Target pharmacies, get a 30-day supply of more than 400
commonly prescribed generic drugs for only $4-less than half the Tier 1
copayment for most Health Alliance plans. Find a complete list of eligible
drugs at www.walmart.com or www.target.com.
Buying generic drugs when possible is generally a smart move. Generic
medications are therapeutically equivalent to the corresponding brand-name
drugs, yet on average, are three times less expensive than brand-name drugs.
Ask your doctor if generic drugs are right for you.
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