State of Mississippi Health Insurance Plan
Prime Therapeutics LLC Pharmacy Program
Note: This information does not apply to Medicare eligible retirees, Medicare eligible surviving spouses,or Medicare eligible dependents of retirees and surviving spouses.
The Plan includes a copayment program for prescription drugs. This page summarizes the details of the program and how it works. An enrollee must elect health insurance coverage in order to participate in the prescription drug program. Refer to the webpages on Base Coverage and Select Coverage for information on deductibles.
To be covered under the Plan, prescription drugs must be:
- Prescribed by a physician,
- Dispensed by a licensed pharmacist, and
- Found to be medically necessary for the treatment of the participant’s illness or injury.
Participants may purchase medically necessary prescription drugs at participating retail pharmacies or through the Prime home delivery service, PrimeMail. Specialty medications must be purchased through participating specialty drug providers. Coverage for prescription drugs purchased at a retail pharmacy is limited to a 90-day supply. Coverage for prescription drugs purchased through the home delivery service is limited to a minimum 60-day supply and a maximum 90-day supply. Coverage for prescription drugs purchased through the specialty pharmacy program is limited to a 30-day supply.
When a prescription drug is purchased at a participating retail pharmacy, the participant is only required to pay the appropriate copayment amount (after the applicable deductible is met) or the cost of the drug, whichever is less. There is no claim form to file. When a prescription drug is purchased at a non-participating pharmacy, the participant must file a claim with Prime. The prescription drug claim form is available at www.MyPrime.com. Payment of the claim will be made based upon the Plan’s allowable charge. The participant is responsible for any amount in excess of the allowable charge, plus the applicable deductible and/or copayment.
In most instances, when a generic drug is available and the participant purchases the brand name drug, the participant will pay the difference in the cost of the brand name drug and the generic drug, plus the generic copayment amount.
Prime Customer Service
Prime is available 24 hours a day, 7 days a week to provide assistance to participants. If a participant should experience a problem having a prescription filled or have a question regarding coverage, he may contact Prime at (855) 457-0408.
The co-payments for prescription drugs through the retail and mail order pharmacies are as follows:
Prescription Drug Type
90 Day Supply
|Preferred Brand Drug*||
|Specialty/Other/Non Preferred Drug*||
*Generic mandate applies to brand drugs purchased when a generic is available.
Based on the cost of some generic drugs, copayment other than the generic copayment may apply. The copayment amount of certain covered prescription drugs may be reduced, increased, or eliminated to assist in controlling prescription drug costs.
Copayments for the treatment of diabetes are as follows:
|Retail Pharmacies||Diabetic Management Program|
|Testing Strips and Lancets||1-30 Day Supply||31-60 Day Supply||61-90 Day Supply||90Day Supply (or less)|
Typically, generic drugs cost less than equivalent brand-name drugs. Because the generic drug copayment is less, participants save money when purchasing generic drugs. Participants are encouraged to use generic drugs whenever allowed by their physician. To be covered by the Plan, a generic drug must:
- Contain the same active ingredients as the brand-name drug (inactive ingredients may vary);
- Be identical in strength, form of dosage, and the way it is taken;
- Demonstrate bio-equivalence with the brand-name drug; and
- Have the same indications, dosage recommendations, and other label instructions (unless protected by patent or otherwise exclusive to the brand-name).
Preferred Brand Drugs
A list of preferred brand drugs is maintained by Prime. Preferred drugs are chosen based on their clinical appropriateness and cost effectiveness. Prime may add drugs to the list at any time. Deletions will typically only occur on an annual basis. A copy of the list may be obtained by contacting Prime directly or through the Plan’s website at http://KnowYourBenefits.dfa.ms.gov.
Benefits will be provided at 100% of the allowable charge for annual influenza (flu), pneumococcal infection (pneumonia), Haemophilus influenza type b (Hib), Hepatitis A and B, HPV, measles, mumps, rubella, varicella, meningococcal, polio, rabies, rotavirus, tetanus, diphtheria, and acellular pertussis (whooping cough) vaccines administered by an immunization-certified pharmacist at a participating pharmacy. In addition, benefits will be provided at 100% of the allowable charge for non-Medicare participants age 60 and over who receive the herpes zoster (shingles) vaccine from an immunization-certified pharmacist. Participants must use a Prime participating pharmacy in order to receive these benefits. A prescription may be required.
Home Delivery Service
Participants can enjoy the convenience of receiving their medication(s) by mail by using Prime’s home delivery program, PrimeMail. In order to participate in the home delivery program, participants must first register as a user to establish health, allergy, and payment information.
Two Steps to Enroll in the Home Delivery Service
- Call physician and obtain a new 90-day prescription;
- Complete the PrimeMail home delivery program Enrollment Form.
• Initial registration can be completed:
◊ online at www.MyPrime.com via the “Register Now” link;
◊ by calling (855) 457-0408 and selecting Option 1;
◊ by printing the Enrollment form and mailing it to the address on the form.
• Prescription Order Form can be:
◊ faxed to the Prime home delivery program by the physician’s office or;
◊ mailed to the Prime home delivery program by the participant.
Participants should order refills 7-10 days before their supply runs out. This will allow ample time for shipping and delivery of the order.
Some Helpful Tips When Using The Home Delivery Service
- Verify the deductible and/or copayment amount by calling Prime at (855) 457-0408.
- Make sure the prescription is written for a 90-day supply.
- To ensure the order is not held up due to insufficient payment, participants will need to provide a valid credit card number during the registration process. Prime will contact the participant to authorize any copayment amounts more than $399 before billing the credit card.
- Please allow 7-10 days for order to arrive.
- Participants may obtain additional home delivery registration forms and prescription order forms at www.MyPrime.com
A prescription submitted to the home delivery service for less than a 90-day supply will be charged the same copayment as for an entire 90-day supply. Coverage for prescription drugs purchased through the home delivery service is limited to a minimum 60-day supply and a maximum 90-day supply. Prime may suspend home delivery service if an enrollee carries a delinquent balance on his account.
A home delivery copayment will be applied to each unit for any covered drug or medical item that requires a specific copayment per unit or vial, such as insulin.
Certain prescription drugs require prior approval. The prescribing physician must contact Prime at (855) 457-0408 for prior authorization. The physician must provide appropriate documentation of medical necessity. Only the physician can request prior authorization approval.
Examples of prescription drugs requiring prior authorization include, but are not limited to:
- medications for treating acne
- androgens and anabolic steroids
- growth hormones
- medications for treating hepatitis B & C
The quantity of some prescription drugs may be limited based on medical necessity. Some prescription drugs are indicated only for a specific therapeutic period or in certain amounts. If the quantity of a covered prescription drug, as prescribed by the physician, is not approved by Prime, the physician must contact Prime for prior approval of additional quantities. Approval will require appropriate documentation of medical necessity. The fact that a physician has prescribed, ordered, recommended, or approved a prescription drug, does not, in itself, make the prescription drug medically necessary for purposes of coverage under the Plan.
Some prescription drugs require step therapy. Step therapy is a process that optimizes rational drug therapy while controlling costs by defining how and when a particular drug or drug class should be used based on a patient’s drug history. Step therapy requires the use of one or more prerequisite drugs that meet specific conditions prior to the use of another drug or drugs.
There are some circumstances when a participant will be allowed to obtain an early refill of a prescription drug for purposes such as going on vacation, for a dosage change during the course of a treatment, or for lost or destroyed medication. The participant’s pharmacist may contact Prime to obtain authorization for an early refill or advance supply of a medication. Early refills are limited to two refills per medication per 12 months.
Prime Specialty Drug Management Program
The Prime Specialty Drug Management Program provides access to specialty medications with the convenience of express mail delivery. Specialty medications must be purchased through an approved specialty pharmacy in order to be covered. Participants have access to a Specialty Care Team staffed by experienced pharmacists specially trained in complex health conditions and the latest medication therapies. Participants can call Prime at (877) 627-6337 for information on other approved specialty pharmacies.
The copayment amount for specialty medications is $70 per 30-day supply if purchased through a network provider. There is no out-of-network copayment since all specialty drugs must be purchased through an approved specialty pharmacy.
Specialty pharmacies provide medications for many chronic conditions, such as:
• Multiple Sclerosis
• Rheumatoid Arthritis
• Gaucher’s Disease
• Cystic Fibrosis
• Hepatitis C
• Respiratory Syncytial Virus
• Growth Hormone Deficiency
• Crohn’s Disease
• Pulmonary Hypertension
Limited Distribution Drugs
Limited distribution drugs are only available through select specialty providers as determined by the drug manufacturer. Access to limited distribution drugs is available through other specialty providers in the Prime Specialty Drug Management Program. For assistance with obtaining a limited distribution drug and with locating an approved distributor, contact Prime at (877) 627-6337.
Coverage is provided for over-the-counter medications containing pseudoephedrine. A prescription is required.
Coordination of Benefits
When a participant has other health insurance coverage which is primary, a prescription drug claim may be filed for secondary coverage under the Plan. To file a claim, a copy of the explanation of benefits from the primary insurance carrier along with a copy of the receipt from the pharmacy must be attached to a prescription drug claim form. This form is available at www.MyPrime.com. The claim is processed by Prime and reimbursement is made to the enrollee based upon the Plan’s allowable charge, less the amount paid by the primary carrier, less the applicable copayment for that prescription drug.
What Drugs are not Covered?
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