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Prescription Drug Coverage: Non Medicare / Commercial Plans

Prescription Drug Coverage & Medication Management
Prescription Drug Coverage & Medication Management
(Highlights drug coverage by plan, prior approval guidelines, critical forms and other helpful information for healthcare providers and consumers)

Non Medicare/Commercial Plan Executive Summary

Non-Medicare plans typically are provided with several available options. What distinguishes most plans in this category are the patient populations they serve.  Most plans are multi-tier with between 3-5 tiers per plan. These plans often promote the use of mail order pharmacies. Mail order pharmacies are offered to increase patient compliance and decrease costs. Most medications are filled for a 90 day supply when ordered through the mail. Most plans also direct patients to fill prescriptions through network pharmacies when not utilizing mail order pharmacy. Plans require patients to pay higher costs when using out-of-network pharmacies.

Plan Name (alphabetical order) Company Name Formulary List Site / pdf Prior Authorization Critera Prior Authorization Form/ Specialty Medication Forms Specific Forms by Drug Mail Order/ Specialty Pharmacy Other Helpful Links Workers Compensation
Aetna Aetna Link Link pdf No Mail Order Pharmacy N/A Workers Compensation
BCBS of NC BCBS of NC Link Link pdf Yes Mail Order Pharmacy N/A N/A
Caremark Primary/Preferred Caremark Link pdf pdf N/A Mail order Form N/A N/A
Caremark Performance Caremark pdf pdf N/A N/A Mail order Form N/A N/A
Cigna Cigna Link Link pdf No Specialty Medication Form Other Medical, Dental, and Pharmacy Forms Pharmacy Benefit (Scriptnet)
Specialty Pharmacy Participating Pharmacy Finder
Coventry Health Care- Carolinas Coventry Wellpath Link Link pdf Yes Mail order Exclusion List  N/A Workers Compensation
pdf Mail order Form
Express Scripts Basic Express Scripts pdf Link Link N/A N/A N/A Workers Compensation
Express Scripts High Performance Express Scripts pdf Link Link N/A N/A N/A Workers Compensation
Express Scripts National Preferred Express Scripts pdf Link Link N/A N/A N/A Workers Compensation
Federal Employee Program Standard BCBS pdf Link pdf Yes Mail Order Pharmacy Other Pharmacy Forms Including Overseas, Mail order, and Retail Reimbursement Forms N/A
Federal Employee Program Basic BCBS pdf Link pdf Yes Mail Order Pharmacy Other Pharmacy Forms Including Overseas, Mail order, and Retail Reimbursement Forms N/A
First Carolina Care First Carolina Care pdf Link pdf Yes Mail Order N/A Workers Compensation Claim Form
HealthSmartRx   pdf N/A N/A N/A N/A N/A Workers Compensation
Humana High Deductible Humana pdf Link pdf N/A N/A N/A N/A
Humana Rx3 Humana pdf Link pdf N/A N/A N/A N/A
Humana Rx4 Humana pdf Link pdf N/A N/A N/A N/A
Humana RxImpact Humana pdf Link pdf N/A N/A N/A N/A
myCigna Health Bronze Cigna Link Link N/A N/A N/A N/A N/A
myCigna Health Gold Cigna Link Link N/A N/A N/A N/A N/A
myCigna Health Silver Cigna Link Link N/A N/A N/A N/A N/A
North Carolina Medicaid North Carolina Medicaid pdf Link pdf Yes N/A N/A N/A
North Carolina State Health Plan (Enhanced) North Carolina State Health Plan pdf  Link Link Yes Mail Order N/A N/A
Specialty Pharmacy
North Carolina State Health Plan (Traditional) North Carolina State Health Plan pdf Link Link Yes Mail Order N/A N/A
Specialty Pharmacy
Northwest Pharmacy Services   pdf N/A N/A N/A Mail Order N/A N/A
OptumRx 3 Tier Classic Optum N/A N/A pdf Yes Mail Order Pharmacy N/A N/A
OptumRx 3 Tier Performance Optum N/A N/A pdf Yes Mail Order Pharmacy N/A N/A
OptumRx 4 Tier Performance Optum N/A N/A pdf Yes Mail Order Pharmacy N/A N/A
ScriptNet   pdf N/A N/A N/A N/A N/A N/A
ScriptGuideRx   pdf Link pdf Yes Mail Order Pharmaa N/A N/A
TriCare TricCare Link Link pdf  Yes Mail Order Pharmacy N/A Workers Compensation General Website
Participating Pharmacy Finder
Unicare   N/A N/A N/A N/A N/A N/A N/A
United Healthcare (4-Tier) United Healthcare pdf Link pdf Yes Specialty Medication Enrollment Forms Personalized Medication Website  
United Healthcare (Advantage) United Healthcare pdf Link pdf Yes N/A N/A N/A
United Helath Traditional United Healthcare pdf Link pdf Yes N/A N/A N/A
Veterans Administration National Formulary Veterans Administration Link N/A pdf No Mail Order Pharmacy Personalized Health Website N/A

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