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Prescription Drug Benefit
Available only with Balance 1000, Balance 1500 and Welcome 500 Plans
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This page
provides an overview of the prescription drugs benefit. You can also jump
to Frequently Asked Questions
below. |
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Overview |
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This plan covers
certain prescription drugs. These covered drugs are on a list that
includes generic and some brand-name medicines. This list is known
as the
Drug Formulary. |
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Drugs not on this
list may also be covered, but at a greater cost to you. In some cases, a doctor must ask for a review
and Group Health must approve the request. |
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Items that are not covered include: |
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Over-the-counter medicines (examples include cosmetics or drugs
for motion sickness, diarrhea, etc.) |
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Dental
prescriptions |
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Drugs used
for non-FDA-approved reasons |
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Certain
prescription drugs |
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Getting Prescriptions Filled
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A
prescription from a doctor practicing at a Group Health-owned medical
center should be filled at a Group Health-owned pharmacy, so Group
Health has a complete medication profile for you. Group Health owns
and operates 24
pharmacies in Western Washington, four pharmacies in Spokane, one in
Coeur d'Alene, and a
mail-order service. |
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If
you live outside of this service area and see a doctor who is
contracted with Group Health, you can have your prescriptions filled
at most pharmacies in your community. Find a pharmacy near you by
browsing the lists for
Group Health Pharmacies and
Community Pharmacies. |
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You can also use the Group Health
mail-order pharmacy by filling out a
Prescription Mail-Order Request Form
and sending it in. |
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To fill a prescription: |
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You will need your Group Health
member identification number. |
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You will need to pay your
cost-share for your medication when you pick it up. |
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A maximum 30-day supply per copayment
is usually provided. |
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Prescription Refills |
You can
refill your regular medications by calling your usual pharmacy at
least one business day ahead of time. This is the best option if you need refills
quickly. However, Group Health also offers several convenient ways to
order your medications and have them delivered to your doorstep with no shipping
charge.
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Order
online (refills only) |
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Use
Group Health's automated touch-tone phone system (refills only) |
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Fax or
mail your prescription to Group Health (new prescriptions and
refills) |
Read more about these options
here.
Members who use a pharmacy that isn't owned by Group Health will need
to transfer prescriptions to their central system before using the
mail-order service for the first time. |
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How To Contact
Customer Service
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For non-medical questions, call the
Pharmacy Customer Service staff at 206-901-4450 in Seattle or
1-800-245-7979 toll-free. Customer service representatives are
available from 7:30 a.m. to 6:00 p.m. on
weekdays, 8:00 a.m. to 5:00 p.m. on
Saturdays and 8:30 a.m. to 5:00 p.m. on
Sundays. Call 206-901-4450 in Seattle or 1-800-245-7979 toll-free.
You can also send e-mail to
pharmacy.c@ghc.org. |
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Emergency
Prescriptions |
| If it's
not possible to get a prescription filled at a Group Health pharmacy,
you may fill it at the pharmacy of your choice at your expense.
Note: You will not be reimbursed for refills or chronic
medications. |
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Allergies To
Prescriptions |
| If you
are allergic to any drugs, it is very important to tell your doctor
and pharmacist. They will include this information in your records. |
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Pharmacy Mail-Delivery Service |
Order your Group Health prescriptions online, or by phone, fax, or
mail, and have them shipped free of charge anywhere in the United
States. Save yourself the trouble of fighting traffic and waiting in
line at the pharmacy.
Your order may take 5 to 7 business days to arrive. The best time to
reorder is when you have about a 14-day supply of your medication
remaining. This will ensure that you receive the medication you need,
when you need it.
Group Health ships medications via the U.S. Postal Service at no cost
to you. They ship medications containing certain controlled substances
via UPS (United Parcel Service). |
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Ordering Online
Group Health offers online ordering for refills only. You can order
prescription drugs,
over-the-counter products, and special medical items through your
MyGroupHealth account and have them delivered free of charge. To use
this service, you must register with MyGroupHealth and upgrade
your account to get access to the enhanced online services. Once you've done that, you'll find a link
to order refills every time you log in to your MyGroupHealth
account.
Your MyGroupHealth site shows a list of
all prescriptions you've filled in the last 12 months. Pay with a
credit card to order up to three months' worth of refills, and
they'll usually arrive in less than a week. |
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Touch-Tone Phone
System
This
service is also available for refills only. Group Health's 24-hour
automated phone line walks you through the process of ordering
refills using recorded messages and keypad options. You will need
your member identification number, mailing address, prescription
number(s), and your payment information readily available. You can
pay using a credit card, check or money order. Call the touch-tone
phone system toll-free 1-800-245-7979.
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Fax or Mail
This service is available for new
prescriptions and refills. Download and print the
Prescription Mail-Order Request Form
to send Group Health your prescription and payment information.
For first-time orders, be sure to include the written prescription
from your physician. The fax number and mailing address are on the form.
You
can also ask your physician to fax your prescription to Group
Health at 206-901-4443 or to call toll free
1-800-245-7979 toll-free. They'll need your member identification
number and a phone number where you can be reached.
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How To Transfer A Prescription
If you use
a pharmacy that isn't owned by Group Health, you can still use
mail-order services.
When you log in to your MyGroupHealth Web account, the "Refill
Prescriptions" area of the site has an electronic transfer form to move your
prescription into Group Health's system before ordering.
Other customers can fill out this
transfer form
and mail or fax it to Group Health. Once your prescription is in Group
Health's central system, you'll be able to use the mail-order services
mentioned above.
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Frequently
Asked Questions (FAQ's)
Using and Storing Medications
Safely
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1. |
How will I know if my new prescription is safe to take with my current
medications?
Pharmacists use a
state-of-the-art drug interaction computer system to identify and
review all potential drug interactions. We will notify your physician
of any significant interactions.
It is important
that you tell us about all of the medications you are currently
taking, including over-the-counter drugs, dietary supplements, and
herbals. That way we can be sure to identify all potential drug
interactions when you receive a new prescription.
You will be
notified by phone if the process of resolving a drug interaction
causes a significant delay in filling your prescription. |
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2. |
What should I do if I have a bad reaction to my medication?
If the reaction seems serious or life-threatening — for example, if
you have wheezing, tightness in the chest, fever, itching, bad cough,
blue skin color, fits, or swelling of your face, lips, tongue, or
throat -- contact your nearest emergency room or dial 911.
If it seems less
threatening, a pharmacist would need to speak to you directly to offer
the best course of action and to update your patient profile if
necessary to avoid future reactions. Please contact us at the phone
number printed on your prescription bottle. |
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3. |
What should I do if my medication looks different from last time and
there is no note telling me that it has changed?
If there was no note with your prescription bottle, check the bottle
for a sticker that indicates it is a different brand of the same
medicine. If there is no such sticker, please contact us at the phone
number printed on your prescription bottle. If it is outside of our
normal business hours, please call the consulting nurse toll-free at
1-800-297-6877 (Western Washington) or 1-800-826-3620 (Eastern/Central
Washington and North Idaho). A pharmacist is available through the
consulting nurse service weekdays between 6:30 a.m. and 8:30 p.m.,
Saturdays between 7 a.m. and 5 p.m., and Sundays 2:00 p.m. to 8:30
p.m. |
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4. |
What
should I do if I miss a dose of my medication?
Take the missed dose as soon as possible. If it is almost time for the
next dose, skip the missed one and return to your regular schedule. Do
not take a double dose or extra doses. |
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5. |
How do I know
when my medication is expired?
Any prescription filled by Group Health will have the expiration date
(month and year) marked clearly on the label in the upper right-hand
corner. This is the date given to us by the manufacturer at the time
of the production of the medication or one year from the date the
pharmacy filled it, whichever is sooner. It is good through the end of
the month noted on the label. |
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6. |
How should I store my
medications?
Most prescriptions should be stored at room temperature in a cool, dry
place away from moisture and preferably out of direct sunlight and/or
heat. The medicine cabinet in the bathroom is not the best place for
medications. Moisture and temperature may affect the stability of the
medication, which means that it may not last as long as it would if
stored properly. Some prescriptions should be refrigerated. Please ask
your pharmacist how best to store your medications. |
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Group Health's Drug Formulary |
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7. |
What are
formularies and why do they exist?
A formulary is a list of medications that are covered as a pharmacy
benefit. Drugs are evaluated for
efficacy, safety, toxicity, and cost. The medications in the formulary
are constantly being reviewed and revised.
Formularies
exist in order to allow health care providers to offer the most
effective drug therapy possible with limited resources in today's
environment of increasing drug prices. Having a formulary allows Group
Health to offer the safest, most effective, and least costly health
care possible.
The Group Health formulary is developed by their Pharmacy and
Therapeutics Committee (P&T Committee). This committee, composed of
physicians from various medical specialties, reviews the medications
in all therapeutic categories based on safety, effectiveness, and
cost, and selects the most cost-effective drugs in each class.
The P&T Committee regularly reviews new and existing medications to
ensure that the Group Health formulary remains responsive to the needs
of members and providers. The formulary is updated periodically and is
subject to change. |
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8. |
Why can't
I get a drug I see in a magazine or on TV?
Most Group Health plans cover prescription drugs that are on a list
called a drug formulary. The list includes generic and some brand-name
drugs. These are the drugs we feel are the safest and most effective
medications for a particular problem. Doctors on our Pharmacy and
Therapeutics Committee decide what drugs will be covered. They review
each drug's efficacy, safety, toxicity, and cost.
Group Health doesn't jump
on the media bandwagon. We want to make sure a drug is safe and does
just what it's supposed to do without causing any serious
complications. Fen-Phen (for obesity) and Rezulin (for diabetes) are
just two examples of drugs we did not approve for our formulary.
Looking back, these were very smart decisions. Both drugs were later
withdrawn from the market because they were found to cause serious
health problems. |
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Antibiotics |
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9. |
Why do I have to take all of my antibiotics if I feel better after a
few days?
Antibiotics continue getting rid of bacteria that cause infection even
after you start feeling better. If you stop taking them too soon
(before your pills are gone) the bacteria that are still in your
system can change so that they are not vulnerable to the medication
anymore. Sometimes these bacteria can multiply and cause your original
infection to return. This relapse may have to be treated with a
different, more potent antibiotic, since the bacteria may have become
resistant to the one you were taking at first. |
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10. |
Why don't I
need antibiotics when I have a cold?
Viruses cause colds and antibiotics are generally not effective
against viruses. The best medicine for colds is still rest, plenty of
fluids, and, if you need symptom relief, over-the-counter cold
products. If you do not feel better within 10 days, please notify your
physician's office. |
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Hormone Replacement
Therapy |
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11. |
Where does the estrogen come from in the different types of estrogen
pills?
Premarin: mare (female horse) urine
Estrace (Estradiol): soy
Estratab: Mexican yams
Menest: soy |
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Generic Drugs
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12. |
What are generic drugs?
When a company identifies a drug in the laboratory, that company is
granted a patent on the drug for a period of 20 years. During the life
of the patent, no other manufacturer is allowed to produce or sell the
same drug product without the patent-holder's approval, thus
eliminating direct price competition. Patent protection allows the
original drug company to recoup the money it spent for research and
marketing, and to make a profit.
After the patent expires,
other pharmaceutical manufacturers may develop, test, and market the
same drug. These identical products, "generic drugs," contain exact
quantities of the same active ingredient in the same dosage form as
the innovator's product. Group Health has significantly
reduced total drug expenditures without compromising quality by using
generic drugs. This strategy has resulted in savings to you in the
form of lower rates and prescription prices. |
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Measuring Liquid
Medications |
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13. |
Are cc and ml the same amount?
Yes, cubic centimeter (cc) and milliliter (ml) are equivalent
measurements. For example, 5 cc equals 5 ml. |
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14. |
What is the metric measurement of a teaspoonful? A tablespoonful?
One teaspoonful is equal to 5 ml, and one tablespoonful is equal to 15
ml. Remember not to use your own household silverware to measure these
quantities. The volumes of household spoons vary widely. |
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Copay Questions |
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15. |
Why do I have to pay full price for over-the-counter drugs?
Over-the-counter drugs are not covered under your drug benefit and
therefore not eligible for a copay. |
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16. |
I was given a six-week supply of medicine. Why am I charged two copays
for one prescription?
One copay covers a 30-day supply. A second copay is charged for
anything more than a 30-day supply. A six-week supply is 42 days,
hence an additional copay. |
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17. |
I've had a prescription that only includes six pills, but I'm still
charged a copay as if it were a full 30-day supply. Why?
You are charged a copay whether your prescription calls for six pills
or 60 pills. A single copay is for one month's supply or less. If you
only have to take three days worth of pills, you're still responsible
for a full copay unless the prescription charge is less than the
copayment. You then pay the prescription charge. Some pills are very
expensive, often $1 or more per pill. Your copay can still be a
bargain compared to the actual cost of the pills. |
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18. |
Why am I charged another copay if my doctor changes my prescription?
Let's say, for example, you have an infection and your doctor gives
you a prescription. Your doctor also had you take a lab test to make
sure you received the most appropriate antibiotic for your particular
infection. The lab results alert your doctor to a better drug for your
particular problem and your prescription is changed. Now you have a
new prescription so you need to pay another copay for the new
medicine. The same thing can happen if you have an allergic reaction
to a drug and it needs to be changed. Another prescription requires
another copay. |
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General Information |
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19. |
What is my member
identification number?
The number you should use when ordering prescriptions is located on
your insurance card. For Group Health Cooperative members in Western
Washington, this number is labeled as "identification number" or
"consumer number." For members of Group Health Options, it may be
labeled as "member number." For Group Health members east of the
Cascades, it may be listed as your "Web access/Rx ID number." |
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20. |
How can I learn more about the medication my doctor prescribed for me?
Group Health Cooperative members can browse through the list of
medications in Healthwise Knowledgebase. |
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21. |
What if I have other
questions?
Please call us during normal business hours, which are from 7:30 a.m.
to 6 p.m. Monday through Friday and 9 a.m. to 1 p.m. every Saturday.
Please call us at the phone number printed on your prescription
bottle. |
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Important
Information About This Benefit Summary |
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This
is a brief summary of benefits; it is not a contract or a certificate of
coverage. The complete terms of coverage are determined by the carrier's
contract. While we have accurately represented the information in this
Benefit Summary as of the time it was published, should any discrepancies
exist between this Benefit Summary and the carrier's contract, the carrier's
contract shall prevail. Please refer to the carrier's contract for a
complete statement of benefits including waiting periods, limitations and
exclusions.
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