Duke HR - Health & Dental Benefits

Effective March 1, 2010, medical plan participants will have the option of purchasing long-term maintenance medications (90-day supply) at one of the participating Duke pharmacies under the same guidelines as Medco Mail Order, which offers a lower co-payment and is not subject to the $100 deductible for brand/non-formulary drugs.

You can use a health care reimbursement account to pay for pharmacy co-pays and deductibles. You can order medicine through Medco's mail order program using the Wageworks™ health care card without the need for a credit card, check or money order.

Each participant in Duke Basic must satisfy a $100 prescription drug deductible before the plan begins to pay benefits under the co-pay structure described above. For Duke Basic, home delivery is mandatory for maintenance medications. Maintenance medications are those medications that a provider has prescribed for regular (i.e., daily) use, and include (but are not limited to) heart/ulcer/blood pressure medication, hormone therapy, and birth control pills. After three purchases of maintenance medications at a retail pharmacy, home delivery must be used. Some medications prescribed for certain uses must receive authorization before they can be covered.

Most major pharmacy chains are included on the Medco Health list. To locate a participating pharmacy, log on to www.medcohealth.com, or call 1-800-717-6575.

Pharmacy Benefits

Medco Health, a national pharmacy benefit manager, provides pharmacy benefits for all four medical plans. Co-pays and deductibles vary depending on the type of medicine prescribed (generic, brand or non-formulary), the length of the prescription, and the place of purchase.

Co-pay & Deductible Structure for Retail Pharmacies (up to 34-day supply)*

An annual $100 deductible per person applies to brand and non-formulary prescriptions filled at retail pharmacies, where drugs are limited to a 34-day supply. This deductible means each person covered by the medical plan must satisfy the $100 deductible for brand and non-formulary drugs purchased at a retail pharmacy before the plan begins to pay benefits under a co-pay structure. There is no deductible for generic drugs (except for Duke Basic).

The retail co-pay structure for short-term medications, controlled substances, and compounded medications is listed below.

After your third purchase of the same medication, your prescription is considered to be a long-term medication and you will pay a higher cost if you continue to purchase it at a retail pharmacy. Specifically, you will pay 50 percent of the cost of the prescription, subject to a minimum and maximum. The minimum is $10 (or cost of drug if less) for generic; $55 for brand; and $65 for non-formulary drugs. The maximum is $25 for generic; $125 for brand; and $135 for non-formulary drugs.

To avoid paying more for your long-term medications, use the Medco Mail Order Pharmacy or beginning March 1, 2010, participating on-site Duke pharmacies (Duke Clinic, Duke Children's Hospital, and Duke Raleigh Hospital). Reasons to consider using the mail order pharmacy or participating on-site Duke pharmacies include reduced co-pays and a waiving of the $100 deductible for brand and non-formulary drugs. (See chart below for details.)

*Participants in the Duke Basic medical plan have an annual $100 deductible for all prescription drugs and are required to use the mail order program or participating on-site Duke pharmacies (as of March 1, 2010) after the third purchase of a long-term medication.

Please note: Injectable fertility drugs are not reimbursed according to our standard pharmacy benefit, more information is available at the InfertilityBenefits web site.

Co-pay Structure for Medco Mail Order Pharmacy (up to 90-day supply)

You will save time and money by filling your recurring, long-term medications through the mail order program or participating on-site Duke pharmacies (as of March 1, 2010). Medications through Medco can be home-delivered in a 90-day supply at a discounted co-pay without a deductible. Your prescription should be written for a 90-day supply because a prescription for less than 90 days will still be charged a 90-day co-payment.

*The co-payment (50% of the total cost of the medication) will also be subject to the following minimum and maximum co-payments. The minimum is $10 (or cost of drug if less) for generic; $55 for brand; and $65 for non-formulary drugs. The maximum is $25 for generic; $125 for brand; and $135 for non-formulary drugs.

Step Therapy

For seven therapies, participants are required to try the generic or target formulary drug (listed below) before the plan will "step up" to pay for alternatives that are more expensive. These therapies are: