Pharmacy Benefits
 

Meet Your Pharmacy Advocate
Preferred Pharmacies
Mail Order Pharmacy
Over-the-Counter Benefit
Medicine Cabinet Alerts


Drug Lookup Tool - New tool effective 1/1/13

This tool is designed to give you up-to-date information on the Manatee YourChoice Drug Formulary*.  Type the name of the drug you want to look up in the area that says "Drug Name" (Under SEARCH).  It is not rquired to log in to use the drug look-up tool, however, by becoming a REGISTERED ACCOUNT MEMBER you may access the following information:

  • Drug Pricing
  • Drug Look-up
  • Real Time Benefits
  • Locate a Pharmacy
  • My Prescriptions
  • My Account
  • Order Medical Supplies
  • Specialty Pharmacy

*Note:  When using this tool provided by OptumRx, variances in formulary may occur for the following medication categories:  Adult ADHD, Pain, Erectile Dysfunction and Over-the-Counter products.

 Presciption Co-pay (Determine your out of pocket costs)

There is not a tool to determine your exact co-pay nor are pharmacies able to run "test claims", however, you can get an idea or your out of pocket co-pay by following two steps.

  1. Go to the drug look up tool and find where your medication falls on the formulary (generic, fourmulary brand, non-formulary brand).
  2. Use the table below.

Your Pharmacy Advocate can also help you determine your co-pay.

 Co-pay Structure Table:

 

Preferred Retail Network

Non-Preferred Retail Network

Mail Order (90 day supply)

Generic Medication

$0

$10 or 20% of drug cost, whichever is greater

$12 or 15% of drug cost, whichever is greater

Formulary Brand Medication

$15 or 25% of drug cost, whichever is greater

$20 or 30% of drug cost, whichever is greater

$38 or 25% of drug cost, whichever is greater

Non-Formulary Brand Medication

$40 or 45% of drug cost, whichever is greater

$50 or 55% of drug cost, whichever is greater

$75 or 40% of drug cost, whichever is greater


Clinical Pharmacy Advocate

  • Available to help you with any medication-related programs or concerns
  • One-on-one Medication Evaluations with Members
  • Works with your physician to design an affordable and effective medication regimen
  • Contact the Clinical Pharmacy Advocate at (941) 748-4501 x6406 or This e-mail address is being protected from spambots. You need JavaScript enabled to view it

 

Meet your Pharmacy Advocate


Dr. Christopher K. Williams, PharmD

Clinical Pharmacist

Dr. Christopher K. Williams PharmD, grew up in Plant City, Florida and received a Doctor of Pharmacy from the University of Florida. Chris is the new full time Clinical Pharmacist for the “YourChoice” Health Plan. He will assist with any medication related issues, including side effects, drug interactions, generic options, proper drug utilization and patient education. He has clinical experience in many settings, including retail, pain management, Coumadin clinics, hospitals, etc. Chris looks forward to working with the team and becoming involved in the many aspects of Manatee “Your Choice”. We welcome his expertise and experience.
 

 

How to Reduce Out-of-Pocket Expenses

Contact your This e-mail address is being protected from spambots. You need JavaScript enabled to view it for assistance in reducing your out-of-pocket expenses.

GENERIC Medications will generally cost you less than Preferred and Non-Preferred brand medications.  Always ask your physician whether a GENERIC medication can be ordered; If not, ask if a medication from the Preferred Drug List will work for you. You can use the Preferred Drug Lookup Tool located on this site to find preferred medications.

Tablet splitting may also offer some additional savings.

 

Preferred Retail Network Pharmacy Benefit

Filling your prescriptions at Preferred retail pharmacies offers you the best opportunity to save money on your prescription cost.

Your plan includes the following benefits:

  • 90 Day Supply
    No co-pay for generics (free of charge to the member)
  • Minimum of $15 co-pay for preferred brand medications or 25% of the approved cost
  • Minimum of $40 co-pay for non-preferred brand medications or 45% of the approved cost
  • Refer to the section below for Prescription Maximum Out-of-Pocket Expenses
  • Preferred Network Pharmacies

Sweetbay Pharmacies (Florida)
Pelots (Bradenton)

  Click Here to Transfer a Prescription to a Preferred Network Pharmacy

 

Non-Preferred Retail Network Pharmacy Benefit

You can still fill your prescription at other network pharmacies, but be aware that your copay amounts will be higher than those at Preferred retail pharmacies.

Your benefits at non-preferred retail pharmacies include:

  • 30 Day Supply
  • Minimum of $10 co-pay for generics or  20% of the approved cost
  • Minimum of $20 co-pay for preferred brand medications or 30% of the approved cost
  • Minimum of $50 co-pay for non-preferred brand medications or 55% of the approved cost
  • Refer to the section below for Prescription Maximum Out-of-Pocket Expenses

 

Specialty Pharmacy Beneft

           Minimum of 25% up to $150 Prescription Maximum Out-of Pocket Expenses

 

How to Transfer a Prescription to a Preferred Network Pharmacy

  1. Go to or call the pharmacy in which you want your prescription filled (the new pharmacy).
  2. Tell the pharmacy "I would like to transfer a prescription to your pharmacy".
  3. Give the new pharmacy the phone number and prescription number from the old pharmacy.
  4. The pharmacist at the new pharmacy will call the pharmacist at the old pharmacy and transfer the prescription.
  5. Pick up the prescription at the new pharmacy.

Mail Order Benefit

You can use mail order services offered through OptumRx to fill your prescriptions. Go to the Optum Rx Website or call 800-562-6223 for details.

Your mail order benefits include:

  • Up to 90 Day Supply
  • Minimum of $12 co-pay for generics or 15% of the approved cost
  • Minimum of $38 co-pay for preferred brand medications or 25% of the approved cost
  • Minimum of $75 co-pay for non-preferred brand medications or 40% of the approved cost

 

Over-the-Counter Drug Benefit (OTC)

A 30-day supply of the following non-prescription allergy and stomach acid suppressant medications is covered as an over-the-counter prescription benefit:

Oral Allergy Medications

Ocular Eye Medications

Stomach Acid Suppression

Alavert

Alaway

Axid

Alavert D

Zaditor

Pepcid

Claritin

 

Prilosec

Claritin D

 

Tagament

Zyrtec

 

Zantac

Zyrtec D

 

 

 

The medications listed above will be provided free-of-charge when filled at a Preferred Network Pharmacy. A $10 co-pay will apply when the prescription for the OTC drug is filled at a Non-Preferred Network Pharmacy.
 

Prescription Maximum Out-of-Pocket Expense

  • Only eligible prescription co-pay or co-insurance will apply to the maximum out-of-pocket expenses. Specialty Pharmacy, excess of Quantity Limits, Non Prior Authorization Approval, OTC, Plan Limitation and Exclusions are not counted toward the Maximum Out-of-Pocket Expense.
  • The maximum out of pocket expense per prescription is $100 retail and $300 mail order.*
  • Annual maximum prescription out of pocket expense is $1,400 per member and $2,800 per family.*

*Maximum out of Pocket Expenses can be adjusted annually by Board of County Commissioners,  refer to the annual Open Enrollment  Handbook for current values.

 

Prior Authorizations and Other Limitations

The computer software used by the Pharmacy Benefit Manager will evaluate the member’s medication profile and determine whether any limitations apply. It will send a message back to the dispensing pharmacist with information regarding any limitations that have been applied to the prescription. The pharmacist should supply this information to you.

Certain medications are subject to restrictions on their use. The most common restrictions are quantity limitations, age limitations, prior use of preferred medications, step therapy, prior authorizations and gender.

In the case of Prior Authorizations, the member’s physician is responsible for contacting the Manatee Clinical Pharmacist by phone, fax or email to provide the information required to complete the authorization. This process is intended to ensure the safe and appropriate use of the desired medication. Note other important information about prior authorizations and other limitations.

Prior Authorizations may take up to 72 hours or longer depending on response time from the prescribing physician. Call your Pharmacy Advocate for more information on necessary Prior Authorizations, Step Therapy, and Plan Limitations,
(941) 748-4501 x6406.

For more information regarding early refill due to vacation or business travel call
(941) 748-4501 x6412.

 

 

 
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