A prescription plan administered by Medco Health Solutions is available in each of the medical plans offered to Lehigh employees. It covers medications that require a prescription by either state or federal law and that are prescribed by a licensed practitioner. Insulin, insulin syringes, and needles are covered by prescription only. Medco uses a Preferred Drug Step Therapy Program to help manage the cost of prescription drug coverage.
Cost of Prescriptions
Covered individuals pay a percentage of the average wholesale price (AWP) for each prescription filled, and the plan does not limit the number of prescriptions received beyond restrictions of medical necessity, applicable legislation, or plan guidelines.
Up to a 30-day supply of any covered medication can be dispensed at a pharmacy. In addition, participants can receive up to a 90-day supply of covered medications either at a pharmacy or through the mail order prescription program.
For all 30 day supplies of covered drugs purchased at a pharmacy, participants pay:
- 10 percent of the AWP up to a maximum of $25 for each generic prescription
- 20 percent of the AWP up to a maximum of $50 for each brand name prescription.
For all 90 day supplies of covered drugs purchased at a pharmacy or through the mail order program, participants pay:
- 10 percent of the AWP up to a maximum of $75 for each generic prescription
- 20 percent of the AWP up to a maximum of $150 for each brand name prescription.
Non-Covered Items
The following are examples of drugs or other charges not covered under the Medco prescription plan:
- Medications lawfully obtainable without a prescription, excluding insulin;
- Devices or appliances (except for diabetic supplies), such as support garments or other non-medicinal substances;
- Administration charges for drugs or insulin;
- Cosmetic drugs and medications used for cosmetic purposes (e.g., Rogaine [Minoxidil] for hair restoration and Retin-A for individuals over 19 years of age);
- Investigational or experimental drugs;
- Unauthorized refills;
- Vitamins and dietary supplements;
- Infertility drugs;
- Non-insulin injectables;
- Prescriptions covered without charge under Federal, State, or local programs, including Worker’s Compensation; and
- Medications for eligible individuals confined to a rest home, nursing home, sanitarium, extended care facility, hospital, or similar entity.
This listing is neither exhaustive nor all-inclusive. If you have questions about coverage for specific medications, please address them to Medco directly at 866-383-7420. You can also go to Medco’s website at http://www.medco.com.