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How does a pharmacy plan work?
When you visit your doctor, he or she may prescribe medicine for you. Here's how the plan works:
- Take your prescription and member ID card to the pharmacy to get your medicine.
- The pharmacist fills your prescription and checks with your pharmacy plan to see how much to charge you for your prescription.
- Because you have a pharmacy plan, you may pay less for your medicine - the amount you pay is called your cost-share. Your pharmacy plan pays the rest.
- Depending on how your health plan is designed, you may have to pay the full cost at the beginning of your plan year, until you meet your deductible. A deductible is the amount of money that you pay out-of-pocket for covered services, before your plan starts to pay.
How do I know which forms I need to fill out?
What should I do after I enroll?
See if your medicines are on the drug list and your pharmacy is in Prime's network:
- Find your medicines with our Medicine Finder. If you don't see your medicine on the drug list, talk to your doctor about switching to a similar medicine
- Find a network pharmacy near you with our Pharmacy Finder. You can use a non-network pharmacy, but you may pay more for your medicine.
Review requirements for medicines you take. Some medicines on the drug list have special requirements. If your medicine does, talk to your doctor. You may be able to choose a different drug, or you could ask for approval for your current medicine.
- Prior authorization - approval is needed before a medicine will be covered. If your medicine does, talk to your doctor. You could choose a different drug. Or, ask for approval for your current medicine.
- Step therapy - you may need to try a different medicine first. Some drugs aren't covered unless you try another FDA-approved drug first, or your doctor submits an authorization request to Prime.
- Quantity limits - limits how much medicine can be in each fill. Each prescription can only be filled for a specific amount, for example, 14 capsules for 7 days. If your doctor thinks you need a larger supply, he or she must ask for authorization from Prime.