Pharmacy
Benefit Changes Information
FAQ
The Medication Assessment Tool (MAT) is a tool developed to help ThedaCare Health Plan beneficiaries navigate recent changes to pharmacy benefits. With changes to pharmacy benefits occurring in 2023 and beyond, beneficiaries may experience coverage changes to certain medications, and may need to meet certain requirements in order to get those medications at the lowest possible out-of-pocket cost.
By using the MAT, beneficiaries can determine what coverage changes may have been introduced to medications they may be taking and how to obtain those medications at a low out-of-pocket cost.
The MAT, however, differs from the Health Partners formulary. Not all medications will be listed in the MAT. The MAT simply provides information for those medications that have additional coverage requirements beyond those listed in the Health Partners Formulary that have been impacted by changes to the ThedaCare Pharmacy Benefit. For medications not listed in the MAT, please visit the Health Partners formulary (linked below) to determine coverage requirements. Medications will continue to be subject to Health Partners formulary status and coverage requirements. This is why it will be important to determine coverage using both the 2023 Health Partners formulary, here, in addition to determining additional coverage requirements listed on the MAT.
You can think of a health plans drug formulary a lot like products in a grocery store. Most of the time when you go to the grocery store for a particular item, let's say a can of beans, you have a lot of options. There are the familiar brand name beans which are usually a little more expensive, and there are the store (generic) brands, which are usually a little cheaper. If you were to visit another grocery store, you may have some similar options and some different options.
A drug formulary works in a very similar way. A formulary is essentially a listing of medications, both brand and generic, which are available through your health plan, which may be different from plan to plan. Formularies are created and maintained to encourage the use of safe, effective, and affordable treatments.
Medications that are "ON" formulary are those medications that are covered by the patient's prescription plan.
Medications that are "OFF" formulary (or "non-formulary") are medications that are not typically covered by the patient's prescription plan, or those that may be available, but at significantly higher rates.
As a partner on your life-long journey of health, ThedaCare is dedicated to ensuring high-quality outcomes from your medications and commits to providing local access to affordable therapies. These changes allow us to fulfill those missions and provide you with maximum savings opportunities as well.
With health care costs on the rise, the changes set forth will lower copays when prescriptions are filled at a ThedaCare Retail Pharmacy. For full details on changes, please refer to the ThedaCare Annual Benefit Guide, located on the internal HR Sharewell page.
Yes. You maintain the right to utilize any pharmacy of your choice. However, you will find some differences in copay structure when using an external pharmacy. For example:
External Pharmacy:
- Maximum of 30-day supply of medication
- Copay of 30-day generic medication: $10.00
- Copay of 30-day brand name medications: 20% of total cost (AWP), no maximum
ThedaCare Retail Pharmacy:
- Maximum of 90-day supply of medication
- Copay on 30-day generic medication: $5.00
- Copay on 90-day generic medication: $10.00
- Copay on 30-day brand-name medication: 20% of total cost (AWP), maximum of $150.00
- Copay on 90-day brand-name medication: 20% of total cost (AWP), maximum of $250.00
Yes. We understand there are many times where you cannot use a ThedaCare Retail Pharmacy. Therefore, you can fill up to a 30-day supply at an external pharmacy for non-specialty, generic medications. Brand-name medications are allowed two fills at the preferred copay before non-preferred copays take effect with fill three.
Prescriptions can be transferred to your preferred ThedaCare Retail Pharmacy in one of two ways:
1. Visit or call your preferred ThedaCare Retail Pharmacy to request a prescription transfer;
OR
2. Log-in to your MyThedaCare account, click on "My Prescriptions," and follow the prompts to transfer your medications online.
Team members that currently participate in programming that will be impacted by benefit changes will receive specific information mailed to them, including (but not limited to), those who receive prescriptions through a mail pharmacy.
Our ThedaCare Retail pharmacists are happy to meet with you to go over your individual situation. Please reach out to your preferred ThedaCare Retail Pharmacy location to set up a time to meet with a pharmacist.
No. Appointments with our expert ThedaCare Ambulatory Pharmacists are provided at no charge to ThedaCare Health Plan members.
ThedaCare Retail Pharmacies offer free delivery to your home. Call your preferred ThedaCare Retail Pharmacy to schedule your home delivery.
If you work out of state, your prescription can be mailed to you. If this prescription is for a controlled substance, please contact your preferred ThedaCare Retail Pharmacy for more information.
This can be requested in one of three ways:
1. During your initial refill request to the pharmacy, select “Deliver by mail” under delivery method. Note: controlled substances require a signature upon delivery.
OR
2. When you are notified via email and MyChart that a prescription is ready, select “Message My Pharmacy” in MyChart under the medications tab, and indicate that you would now like to have your medication delivered.
OR
3. You can also ask the pharmacy to indicate that your preference for all medications is “delivery by mail”. This will allow for any medication in the future to be mailed to you. Ask a member of the pharmacy staff how to save a payment method to make the process even easier.
If you work out of state, your prescription can be mailed to you. If this prescription is for a controlled substance, please contact your preferred ThedaCare Retail Pharmacy for more information.
This can be requested in one of two ways:
1. During your initial refill request to the pharmacy, select "Curb-side pick-up" under delivery method.
OR
2. When you are notified via email and/or MyChart that a prescription is ready, select "Message My Pharmacy" in MyChart under the medications tab, and indicate that you would now like to have your medication picked up via curb-side pick-up.
*In order to participate in curb-side pick-up, you must also schedule an appointment. This can be done in MyChart or by calling the pharmacy.
You may have the option to pay for your prescription electronically when you are requesting a refill on MyChart. If this is missed, you can always call the pharmacy and provide payment over the phone.
No. In fact, we encourage you to transfer your medication right away to ensure a quick and easy fill process!
The Medication Assessment Tool will provide you with any specific requirements and pricing information to obtain the medication at the lowest cost possible. Medications which fall within the scope of the DSM are included in the Medication Assessment Tool, and will provide you with what to expect as an out-of-pocket costs once any requirements are met, including (if applicable) meeting with an ambulatory care pharmacist or obtaining a copay card for the medication.
For medications not appearing on this list, additional information may be found via the HealthPartners Formulary. This will include information such as need for prior authorization, quantity limits, step therapy, etc.
Lastly, the following Affordable Care Act (ACA) medication classes are available at a cost of $0.00:
- ACA Aspirin DL
- ACA Bowel Prep DL
- ACA Contraceptive
- ACA Fluoride DL
- ACA Folic Acid DL
- ACA HIV PREP DL
- ACA Smoking
- ACA Vaccine DL
Sign up through the prescription manufacturer's website. Medications requiring a copay card to receive the preferred copay will say "Yes" in the Medication Assessment Tool, which you will be able to click on to direct you to the copay card website, where you should complete the enrollment process.
Alternatively, you can visit NeedyMeds.org to search for coupon cards. It is a repository for the vast majority of manufacturer-offered copay cards.
Once signed up, simply call your preferred ThedaCare Retail Pharmacy with the information, bring it in with you to the pharmacy, or upload it to your MyThedaCare account.
Studies have unequivocally shown that patients followed by an ambulatory care pharmacy team have enhanced health outcomes. This is achieved through optimization of medication regimens and compliance, and often reduces future un-needed visits for emergency medicine or hospital admissions.
In other words, by being proactive and visiting with the ambulatory care pharmacy team, we reduce future costs and expenses, both for the health system and for our patients, and improve health outcomes.
Appointments can be made in your MyThedaCare account by selecting the "Schedule an Appointment" option, and then "Other Appointment Needed" and "Pharmacist with Primary Care."
Additionally, you can call ThedaCare Disease State Management Scheduling at 1-920-702-6363 to schedule your appointment with an ambulatory care pharmacist.
No worries! You are allowed to fill two 30-day supplies of medication at the preferred copay if you don't have a visit with the ambulatory care pharmacist in the past 365 days.
If no appointment is completed by the third fill, however, the copay will increase to the non-preferred rate. This provides at least 90 days to schedule and attend an appointment with the Disease State Management Ambulatory Care Pharmacist.
Specialty medications would only be covered at ThedaCare Retail Pharmacy - Shawano at the non-preferred rate. All other medications may be filled at any of our ThedaCare Retail Pharmacies for the lowest possible rate.
One of the members of the multidisciplinary team of providers are pharmacists who play a role in assisting individuals in managing their conditions. A pharmacist deals with both patients and healthcare providers, making them a link between the two parties. Pharmacists are also trained to evaluate medication therapies and identify drug-related problems, enabling them to help patients manage these problems. This is why pharmacists have a significant impact on the development and implementation of disease state management programs. Whenever improvements are needed, they can also provide expert information, especially on medications and pharmacotherapy.
Pharmacists are able to provide personalized patient care by:
- Conducting monitoring for specific diseases
- Providing patient education
- Providing direct patient care
- Helping ensure medication adherence
- Helping reduce inappropriate medication use
- Evaluating disease state management program outcomes
If you require an exception to the pharmacy benefit designs, such as needing to use a non-ThedaCare Retail/Specialty pharmacy or are ineligible for manufacturer copay assistance for medications requiring enrollment in copay assistance, please contact your local ThedaCare Retail Pharmacy, as they will be able to help triage.
Click HERE to view ThedaCare Retail Pharmacy contact information.
If you work out of state, your prescription can be mailed to you. If this prescription is for a controlled substance, please contact your preferred ThedaCare Retail Pharmacy for more information.
All patients with a medication included within the ThedaCare Disease State Management program will need to get a referral from their providers to schedule a Disease State Management clinic visit with an Ambulatory Pharmacist. But, getting a referral is easy.
You can either click here
OR
Click "Referral Form" in the menu.
Once completed, please have the provider fax to the ThedaCare Retail Pharmacy - Shawano (Fax #: 920-993-5031).
Additionally, ThedaCare providers can place patient referrals for a Disease State Management clinic visit with the Ambulatory Pharmacist via Epic REF136.
If you have a question in regards to pharmacy benefit changes that wasn't answered by another question in this FAQ, you can contact ThedaCare Human Resources, as they may be able to further answer any remaining questions you may have.
ThedaCare Human Resources: 1-920-830-5800
Additional Information and Resources
Disease state management aims to prevent or minimize the effects of a disease through integrated care - where your healthcare providers work together to develop the best treatment plan for you. This involves disease management programs that are designed to improve the quality of life and health of persons with chronic conditions and to reduce healthcare costs and complications that are completely avoidable. The idea is to treat chronic conditions more quickly and more effectively so disease progression can be slowed down.
Disease management uses a system of coordinated healthcare interventions and one that empowers patients to work with different healthcare providers to prevent complications and manage complex care needs. It operates on the basis that educated individuals are better able to manage their disorder because they know where to seek and receive better care.
A comprehensive disease state management program comes with more benefits:
- Improve access to care
- Improve patient self-management
- Improve safety and quality of care
- Save patients from high financial costs without sacrificing quality or patient satisfaction
Furthermore, it helps healthcare providers to improve the healthcare programs offered to all ThedaCare patients. Care coordination is one of the primary concerns of these providers and an integrated multidisciplinary disease state management program is the solution.
Patients with a provider external to ThedaCare will need to get a referral from their prescribing provider (the provider that prescribes the patient the medication that they need to see an ambulatory pharmacist for).
Click here
OR
Click "Referral Form" in the menu for the form the provider will need to complete.
Please provide this form to your external provider and have them submit to the ThedaCare Retail Pharmacy - Shawano (Fax #: 920-993-5031).
The below table provides a listing of those medications which require "Step Therapy" in order to obtain medication coverage.
In this context, Step Therapy refers to the process by which the patient tries and fails the preferred medication on the plan, and is able to provide documentation of a reason for failure of the preferred medication. Accepted reasons for failure are listed for each product subject to step therapy.
The purpose of a Step Therapy process in a health plan, such as this one, is multivariate and may be influenced by clinical efficacy, safety, therapeutic alternatives, and maintaining lower plan costs.
| Drug Product (Covered only with approved step-therapy failure) |
Preferred First Line Drug Product | Approved Step Therapy Failure Reason (Must fail based on one of the listed criteria) |
|---|---|---|
| Abrilada | Humira citrate containing | 1. Documented allergic reaction defined as follows: allergic reaction that includes systemic symptoms such as significant hives and pruritus distant to the location of injection and up to and including anaphylactic reaction. Does not include localized reactions. |
| Adalimumab-adaz | Humira citrate containing | 1. Documented allergic reaction defined as follows: allergic reaction that includes systemic symptoms such as significant hives and pruritus distant to the location of injection and up to and including anaphylactic reaction. Does not include localized reactions. |
| Adalimumab-adbm | Humira citrate containing | 1. Documented allergic reaction defined as follows: allergic reaction that includes systemic symptoms such as significant hives and pruritus distant to the location of injection and up to and including anaphylactic reaction. Does not include localized reactions. |
| Adalimumab-fkjp | Humira citrate containing | 1. Documented allergic reaction defined as follows: allergic reaction that includes systemic symptoms such as significant hives and pruritus distant to the location of injection and up to and including anaphylactic reaction. Does not include localized reactions. |
| Admelog | Humalog | 1. Documented allergic reaction |
| AirDuo Digihaler | AirDuo RespiClick | 1. Documented allergic reaction |
| Amjevita | Humira citrate containing | 1. Documented allergic reaction defined as follows: allergic reaction that includes systemic symptoms such as significant hives and pruritus distant to the location of injection and up to and including anaphylactic reaction. Does not include localized reactions. |
| Aptensio XR | Concerta | 1. Documented allergic reaction |
| Basaglar | Lantus | 1. Documented allergic reaction |
| Cotempla XR-ODT | Concerta | 1. Documented allergic reaction |
| Cyltezo | Humira citrate containing | 1. Documented allergic reaction defined as follows: allergic reaction that includes systemic symptoms such as significant hives and pruritus distant to the location of injection and up to and including anaphylactic reaction. Does not include localized reactions. |
| Daytrana | Concerta | 1. Documented allergic reaction |
| Dexcom Continuous Glucose Monitoring System | Freestyle Libre Continuous Glucose Monitoring System | 1. Use of insulin Pump 2. Documented innacurate reading(s) |
| Dextroamphetamine/Amphetamine ER | Adderall XR | 1. Documented allergic reaction |
| Epinephrine Auto-Injection/ Epinephrine 0.15mg/0.15mL Auto-Injection** |
EpiPen | 1. Documented allergic reaction.
2. **If EpiPen is currently on shortage, generic Epinephrine auto-injection products will be covered with override. |
| Fluticasone (generic Flovent Diskus) | Flovent Diskus | 1. Documented allergic reaction |
| Fluticasone (generic Flovent HFA) | Flovent HFA | 1. Documented allergic reaction |
| Fluticasone/Salmeterol (generic Advair Diskus) | Advair Diskus | 1. Documented allergic reaction |
| Fluticasone/Salmeterol (generic AirDuo RespiClick) | AirDuo RespiClick | 1. Documented allergic reaction |
| Glatiramer acetate | Glatopa | 1. Documented allergic reaction |
| Hadlima | Humira 40mg/0.8mL (pens/syringes) | 1. Documented allergic reaction, defined as follows: allergic reaction that includes systematic symptoms such as significant hives and pruritus distant to the location of injection and up to and including anaphylactic reaction. Does not include localized reactions |
| Hadlima (CF) | Humira 40mg/0.8mL (pens/syringes) | 1. Documented allergic reaction, defined as follows: allergic reaction that includes systematic symptoms such as significant hives and pruritus distant to the location of injection and up to and including anaphylactic reaction. Does not include localized reactions |
| Hadlima PushTouch | Humira 40mg/0.8mL (pens/syringes) | 1. Documented allergic reaction, defined as follows: allergic reaction that includes systematic symptoms such as significant hives and pruritus distant to the location of injection and up to and including anaphylactic reaction. Does not include localized reactions |
| Hadlima (CF) PushTouch | Humira 40mg/0.8mL (pens/syringes) | 1. Documented allergic reaction, defined as follows: allergic reaction that includes systematic symptoms such as significant hives and pruritus distant to the location of injection and up to and including anaphylactic reaction. Does not include localized reactions |
| Hulio | Humira citrate containing | 1. Documented allergic reaction defined as follows: allergic reaction that includes systemic symptoms such as significant hives and pruritus distant to the location of injection and up to and including anaphylactic reaction. Does not include localized reactions. |
| Humira 80mg/0.8mL (pens/syringes) | Humira 40mg/0.8mL (pens/syringes) | 1. Documented allergic reaction |
| Humira (CF) * Humira 10mg and 20mg CF products are covered with no step therapy* ** Humira Starter Kits are covered with no step therapy** |
Humira non-CF (40mg/0.8mL pens/syringes) | 1. Documented allergic reaction, defined as follows: allergic reaction that includes systematic symptoms such as significant hives and pruritus distant to the location of injection and up to and including anaphylactic reaction. Does not include localized reactions |
| Hyrimoz | Humira citrate containing | 1. Documented allergic reaction defined as follows: allergic reaction that includes systemic symptoms such as significant hives and pruritus distant to the location of injection and up to and including anaphylactic reaction. Does not include localized reactions. |
| Idacio | Humira citrate containing | 1. Documented allergic reaction defined as follows: allergic reaction that includes systemic symptoms such as significant hives and pruritus distant to the location of injection and up to and including anaphylactic reaction. Does not include localized reactions. |
| Insulin aspart (and biosimilars) | Novolog | 1. Documented allergic reaction |
| Insulin aspart 70/30 mix (and biosimilars) | Novolog 70/30 | 1. Documented allergic reaction |
| Insulin glargine | Lantus | 1. Documented allergic reaction |
| Insulin glargine-YFGN | Lantus | 1. Documented allergic reaction |
| Insulin lispro | Humalog | 1. Documented allergic reaction |
| Insulin protamine lispro mix | Humalog 75/25 | 1. Documented allergic reaction |
| Jornay PM | Concerta | 1. Documented allergic reaction |
| Lisdexamfetamine dimesylate | Vyvanse | 1. Documented allergic reaction.
2. **If Vyvanse is currently on shortage, generic Lisdexamfetamine products will be covered with override. 3. Preferred Brand product (Vyvanse) will assess a generic copay. |
| Lyumjev | Humalog | 1. Documented allergic reaction |
| Metadate CD | Concerta | 1. Documented allergic reaction |
| Methylphenidate ER | Concerta | 1. Documented allergic reaction |
| Mydayis | Adderall XR | 1. Documented allergic reaction |
| Novolin Relion, NPH (Novolin N) | Humulin N | 1. Documented allergic reaction |
| Novolin Relion, regular (Novolin R) | Humulin R | 1. Documented allergic reaction |
| Novolin Relion regular/NPH mix | Humulin 70/30 | 1. Documented allergic reaction |
| Relexxii ER | Concerta | 1. Documented allergic reaction |
| Ritalin LA | Concerta | 1. Documented allergic reaction |
| Semglee-YFGN | Lantus | 1. Documented allergic reaction |
| Sensipar | Cinacalcet HCl | 1. Documented allergic reaction |
| Toujeo | Lantus | 1. Documented allergic reaction |
| Wixela | Advair Diskus | 1. Documented allergic reaction |
| Yuflyma | Humira citrate containing | 1. Documented allergic reaction defined as follows: allergic reaction that includes systemic symptoms such as significant hives and pruritus distant to the location of injection and up to and including anaphylactic reaction. Does not include localized reactions. |
| Yusimry | Humira citrate containing | 1. Documented allergic reaction defined as follows: allergic reaction that includes systemic symptoms such as significant hives and pruritus distant to the location of injection and up to and including anaphylactic reaction. Does not include localized reactions. |
You can find the Health Partners formulary here.
If you have questions about the Health Partners formulary, please feel free to contact Health Partners Member Services at:
1-855-813-3888
ThedaCare Human Resources:
1-920-830-5800
ThedaCare Disease State Management Scheduling:
1-920-702-6363
OR
Schedule an appointment by logging into MyThedaCare and selecting "Schedule an Appointment"