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Prescription Drug Coverage

Prescription drug coverage is included with all medical plans offered by SERS.

  • Express Scripts provides the prescription drug coverage for the following SERS plans: Aetna and Paramount.
  • PrimeTime and AultCare provide their own prescription coverage.

All prescription plans have a formulary of covered medications. The amount you are responsible for paying, known as the co-pay, is based on the medication’s formulary status.

You pay the least for generic medications. You pay the most for brand-name medications that are not on the formulary.

You can get your prescriptions at retail pharmacies or through the mail.

You save money by having prescriptions for maintenance medications mailed to your home. Maintenance medication is taken on an ongoing, long-term basis, such as medicine for high blood pressure.

Prescriptions Not Covered
The following is a partial list of situations or types of medications that are not covered. If you
are unsure if a medication is covered, you can call your prescription plan’s customer service.
  • Prescriptions or medications dispensed in a hospital; these are typically covered under your medical plan
  • Prescriptions covered by Workers’ Compensation
  • Prescriptions for fertility, erectile dysfunction, or cosmetic drugs
  • Over-the-counter drugs and herbal preparations, including homeopathic preparations
Coverage Rules
All prescription plans include these common coverage rules:
  • Prior Authorization - For some medications, your doctor must contact the drug plan before certain prescriptions can be filled. The prescription is only covered if your doctor is able to confirm that the medication is necessary.
  • Quantity Limits - Limits how much of a specific medication you can get at a time.
  • Step Therapy - A process where certain medications that have proven to be safe and effective are tried as the first choice rather than starting with a more expensive prescribed medication.
If you or your doctor believes that one of these coverage rules should not be applied to your
situation, you can ask for an exception. Contact your prescription plan for more information.
Medicare and Prescription Coverage
You have Medicare Part D prescription coverage through your SERS Medicare coverage.
You do not need to buy additional coverage. If you enroll in another Part D plan, SERS is
required to cancel your health care coverage.
 
Some medications and supplies are covered by Medicare Part B, which is part of your
medical plan rather than your prescription drug plan. These include but are not limited to:
  • Glucose test strips
  • Nebulizer medication
  • Transplant-related medications
You will use your medical plan ID card, not your prescription card, to obtain these
prescriptions.
Medicare Coverage Gap (Donut Hole)
When you reach the Coverage Gap, also known as the “donut hole,” SERS continues to help you with your prescription costs. Your co-pays will NOT change just because you have entered the donut hole. For more information, contact Health Care Services toll-free at 800-878-5853.
 
To learn more about the Coverage Gap, watch the video "All About Medicare Part D."
 
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