PPO

Discount Prescription Drug Programme

The Blue Cross Empire Pharmacy Management (EPM) discount prescription drug programme is administered by NextRx. EPM delivers significant savings both to programme participants and to the Organization because of significant price discounts obtained from participating pharmacies. EPM provides a retail pharmacy network as well as a mail order pharmacy through NextRx.
Significant cost savings are passed on to participants in either a participating retail pharmacy or the mail order pharmacy. In respect of drugs obtained at participating retail pharmacies, the discounts are at least 15 per cent off the average wholesale price (AWP) of the drug.

If the physician does not write "Dispense as Written" or "DAW" on the prescription, the pharmacist will fill the prescription with a therapeutically equivalent generic drug if one is available. Discounts for generic drugs are typically higher than for brands, and the discount off the AWP may average 40 per cent or more, depending on the particular generic drug dispensed. The discount for maintenance drugs obtained through NextRx will range from 18 per cent to as high as 50 per cent off AWP, again depending on whether a generic equivalent to the brand-name drug is dispensed. (Maintenance drugs are drugs used on a continual basis for the treatment of chronic health conditions.) Whenever a prescription carries the words "Dispense as Written" or "DAW", the pharmacist or mail order pharmacy will fill the prescription accordingly and no substitution will be made.

The procedure under which prescription drugs are reimbursed through the Empire Pharmacy Management programme is as follows: written prescriptions for drugs are presented at a participating pharmacy of one's choice along with the Empire Blue Cross PPO card (please refer to Annex 6). The pharmacist will fill the prescription for up to a 30-day supply and charge a minimum co-payment of the lesser of $5 or the cost of the medication and a maximum coinsurance of 20 per cent on the discounted price of the drug, or $20. No claim form is required for prescriptions filled at participating pharmacies.

Prescriptions for maintenance drugs may provide for up to a 90-day supply and are economically filled through the NextRx mail order facility, which will charge a fixed $15 co-payment per 90-day prescription. The NextRx claim form supplied with the Empire Blue Cross PPO card should be utilized for ordering maintenance drugs by mail. A new order form will be sent back to you with each filled prescription. The address of the mail order prescription drug facility is as follows:

NextRx
P.O. Box 746000
Cincinnati, OH 45274-6000

It should be noted that New York State law requires pharmacists to dispense an approved generic equivalent drug instead of the brand-name drug, when the doctor does not indicate "Dispense as Written" or "DAW" on the prescription. If your doctor does not specify "DAW" when a generic drug is available, and you request a brand-name drug, you must pay your normal co-pay PLUS the difference between the generic drug's allowed amount and the price of the brand-name drug.

As the prescription drug programme is administered separately by Empire Pharmacy Management, the annual deductible under the Empire Blue Cross PPO plan will not be applied to prescription drugs. At the same time, the prescription drug co-payment will also not count towards meeting the annual co-insurance limit of $1,000.
Prescription drugs obtained outside the United States or within the United States but not through the Empire Pharmacy Management NextRX participating network will be reimbursed but you must submit a claim form to the Blue Cross claims office at the following address in order to obtain reimbursement:

WellPoint Next Rx
P.O. Box 145433
Cincinnatti, OH 45250-5433

There is a special claim form for this purpose that you can obtain online at the insurance website, or from the Insurance and Disbursement Service, room FF-300. Claims that you submit to the Empire Pharmacy unit will be subject to the annual deductible for the medical programme, and to co-insurance. Claims for prescription drugs dispensed outside the United States will be reimbursed at 80 per cent after the deductible, while claims for prescription drugs dispensed within the United States but not through the Empire Pharmacy Management programme will be reimbursed at the rate of 60 per cent after the deductible. In addition, the 20 or 40 per cent co-insurance that you pay for such drugs will not count towards meeting the annual co-insurance limit of $1,000. Besides, attaching a receipt, please fill out the section for each script including the name of the country in which you filled the prescription, the name of the drug, and the currency.