Provider Directory

Using Your Pharmacy Benefit

IBA Health Plans works to provide the highest quality of coverage possible in the most cost-effective environment. With this philosophy, we offer a multi-featured prescription drug benefit package to our employers. If your medical benefits with IBA or PHP include a pharmacy benefit, your employer may offer a single-, two- or three-tier drug benefit program. Each of the drug benefit programs works with the Prescription Drug List (PDL) to offer members many advantages. Understanding how the PDL and different tier benefit programs work will help you get better use from your benefit.

What is a Preferred Drug List?
The Prescription Drug List is a list of generic and brand-name prescription medications that can be used for conditions treated outside of a hospital. The Food and Drug Administration (FDA) has approved all drugs on the list. A team of doctors and pharmacists meet regularly to review and update the list.

How does this affect me?
Single-Tier:
You will pay the same copay for a brand-name or generic drug that is on the PDL. Prescription drugs that are not on the PDL are not covered unless prior approval is granted. You may request that your doctor consider prescribing a medication that is on the PDL.
Two-Tier:
If you are prescribed a generic drug or a brand-name drug with a generic available, you can opt for the lower copay of the generic drug. If you select a brand-name drug on the PDL you will pay the higher copayment. Prescription drugs not on the PDL are not covered unless prior approval is granted. You may request that your doctor consider prescribing a medication that is on the PDL.
Three-Tier:
If you are prescribed a generic drug or a brand-name drug with a generic available, you can opt for the lower copay of the generic drug. If you select a brand-name drug on the PDL you will pay the higher copayment. When your doctor prescribes medications on the PDL, you receive the most value from your prescription drug benefit. You may receive most prescription drugs; however, if the drug is not on the PDL you will have to pay the highest copayment.

How can I make sure I am getting the greatest value from my outpatient drug benefit?
Follow the simple steps outlined for each level of the drug benefit program.

Single-Tier & Two-Tier:

Go to a network doctor.
Ask your doctor to refer to the PDL.
Ask your doctor to prescribe:
- 1st choice: a generic drug
- 2nd choice: a brand-name drug from the PDL
Get your prescriptions filled at a network pharmacy or the www.365wellst.com/medco/partner/uhc.jsp Internet site.
Carry and use your member ID card.

Three-Tier:

Go to a network doctor.
Ask your doctor to refer to the PDL.
Ask your doctor to prescribe:
- 1st choice: a drug from Tier 1, available for the lowest copay
- 2nd choice: a drug from Tier 2, available for the second level copay
- 3rd choice: a drug from Tier 3, available at the highest copay. You may want to ask your doctor to consider if a drug on the 1st or 2nd tier would be appropriate for you
Get your prescriptions filled at a network pharmacy or the www.365wellst.com/medco/partner/uhc.jsp Internet site.
Carry and use your member ID card.

What if my prescribed medication is not on the Prescription Drug List and it's after business hours?
Single-Tier & Two-Tier:
Call IBA Health Plan's Customer Service Department at 800.722.3644 as listed on the back of your member ID card. Our answering service can refer you to the on-call nurse who will work with you to solve the problem.
Three-Tier:
Members with the three-tier benefit will pay the highest copay included in their program for prescriptions not on the PDL. Benefit exclusions per the Certificate of Coverage still apply.

What if my doctor says the preferred drug is not the best choice for me?
Single-Tier & Two-Tier:
Your prescription benefit allows you to obtain prescriptions on the PDL by paying a copay. If your doctor determines there is a medical reason for you to take a drug that is not on the PDL, s/he may seek an exception for you. If the medical reason meets our criteria, approval will be given to cover the drug. In this case, members will pay the standard copayment for the non-preferred drug. If you get the prescription and your doctor has not called IBA Health Plans to get authorization, you will pay the full cost of the medication.
Three-Tier:
Members with the three-tier benefit will pay the highest copay included in their program for prescriptions not on the PDL.

What if my doctor does not refer to the Prescription Drug List?
When you go to the network pharmacy, the pharmacist enters your member number into their computer, and can tell if the medication prescribed by your doctor is on the PDL. If the prescribed drug is not on the PDL and you are a single- or two-tier member, your pharmacist may talk to you and your doctor about changing the prescription so you only pay your copay for the prescription drug. Members with the three-tier benefit will pay the highest copay included in their program for most prescriptions not on the PDL.

What is the difference between brand-name drugs and generic drugs?
A generic medication is basically a copy of a brand-name medication. The color or shape may be different, but the active ingredients must be the same for both. Only the Food and Drug Administration (FDA) tests and allows a generic medication to be made.

Does the Prescription Drug List include both generic and brand-name drugs?
Yes. About 70 percent of the products on the PDL are brand-name drugs. The remaining 30 percent are generic drugs.

How can I get a copy of the Prescription Drug List or check on the coverage of specific medication?
You can view a condensed version of the PDL by visiting the Web page at host1.merck-medco.com/uhc/uhc_formu2006.pdf or a more complete version by calling our Customer Service Department at 800.722.3644 to request a copy by mail. You may also call Customer Service to check on the coverage of a specific medication. Please have your group number, located on your IBA or PHP identification card, available when you call.