FREQUENTLY ASKED QUESTIONS
Where do I find what my copays or coinsurance will be on my prescription drugs?
The amount you pay for your medication(s) can be located in your Plan's Summary of Benefits.
What is an OTC or over-the-counter medication?
These are medications that can be purchased without a prescription. OTC stands for "over-the-counter".
What is a generic equivalent?
A generic equivalent is a medication that contains identical amounts of the same active drug ingredient in the same dosage form and route of administration that is expected to have the same clinical effects and safety profile as another product as designated by the United States Federal Food and Drug Administration (FDA).
Are generic drugs safe and/or effective?
Yes, according to the Federal Food and Drug Administration (FDA) generic drugs are safe and effective. Generic medications must meet the same standards for purity, strength, and quality as brand name drugs. They must be approved by the FDA before they can be sold to consumers. Generics may look different from the brand name medication in color, shape, or size as required by the Federal Food and Drug Administration (FDA). For more information visit the FDA’s Office of Generic Drugs. If you are interested in switching to a generic, you may talk with your pharmacist and/or provider to find out if a generic equivalent is available in the drug(s) you current take, and to determine if a generic is right for you.
What is the prior authorization medication list?
To promote the most appropriate utilization, selected high-risk or high-cost prescriptions or devices require an approval of a prior authorization by our Pharmacy Director. Upon enrollment or upon request, the member will receive a list of prior authorized prescription drugs. These medications are also identified in the formulary with a PA after the drug name. Prior authorization criteria is established by our Pharmacy and Therapeutics Committee with input from plan physicians and consideration of the current medical literature. If a medication is required that is not routinely covered, the provider may present medical evidence to obtain an individual patient exception by submitting a prior authorization request for review.
What is a Step Therapy medication list?
Certain prescription drugs may also be subject to step therapy. We have implemented Step Therapy programs in several drug classes where generics or lower cost brand name drugs are available and equally effective. Step Therapy means, a member would need to try the drug(s) listed as a first line drug, before being able to be prescribed a second line drug. If there is medical documentation and/or prescription history to indicate that the first line drug was unsuccessful, or that you are unable to attempt a trial of the first line drug, then your physician may submit a drug prior authorization for review. If approved, the authorization will allow you to move directly to the second line of drugs in that drug class.
What can I do if my prescription drug requires a Prior Authorization, or is not covered?
As a member of the Gundersen Health Plan, you may initiate an exception request process. For your convenience, we have prepared a form that you may complete and submit on-line, by fax or by mail to us. To complete the drug exception request click here.
What are ancillary charges?
Ancillary charges refer to the difference in cost between a brand and generic medication. Ancillary charges apply whenever a member or provider chooses a brand name medication when a generic equivalent is available.
What is mail service pharmacy?
Mail service pharmacy is a convenient, home delivery pharmacy. By using mail service pharmacy you can get up to a 90-day supply of any medication. Your medication will be delivered to your door in a timely, convenient, confidential package. Senior Preferred and other plans may or may not include a mail order benefit. For more information on how to use the pharmacy mail order services, go to http://www.fairview.org/Pharmacy/Mailservice/index.htm.
How do I request reimbursement for a prescription I paid for myself?
When purchasing prescription medications, you are encouraged to use your Pharmacy Prescription Card. If for some reason you are unable to utilize your pharmacy card, and are required by the pharmacy to pay for the medications, you may submit your itemized pharmacy receipt to us. Prescription medications purchased from a participating or non-participating pharmacy will be reimbursed through our Pharmacy Benefits Management (PBM) at our current discount contracted rates. Any difference between the discount contracted rate and what the provider has billed will be your responsibility.