Clinical Pharmacy Advocate

  • Available to help you with any medication-related programs or concerns
  • One-on-one Medication Evaluations with Members
  • Works with your physician to design an affordable and effective medication regimen
  • Contact the Clinical Pharmacy Advocate at (941) 748-4501 x6406

How to Reduce Out-of-Pocket Expenses

GENERIC Medications will generally cost you less than Preferred and Non-Preferred brand medications.  Always ask your
physician whether a GENERIC medication can be ordered; If not, ask if a medication from the Preferred Drug List will work
for you.
A Preferred Drug List is provided to each member on a yearly basis.  You can also use the Preferred Drug Lookup Tool
located on this site.

Voluntary Tablet Splitting Program

Preferred Retail Network Pharmacy Benefit

Filling your prescriptions at Preferred retail pharmacies offers you the best opportunity to save money on your prescription
cost.
Your plan includes the following benefits:

  • 30 Day Supply
  • No co-pay for generics (free of charge to the member)
  • Minimum of $10 co-pay for preferred brand medications or 20% of the approved cost
  • Minimum of $30 co-pay for non-preferred brand medications or 40% of the approved cost
  • Refer to the section below for Prescription Maximum Out-of-Pocket Expenses
  • Preferred Network Pharmacies
  • Sweetbay Pharmacies (Florida)
  • Pelots (Bradenton)
  • Foster Drugs (Bradenton)

Refer to Prescription Plan Home page  for current directory
Non-Preferred Retail Network Pharmacy Benefit

You can still fill your prescription at other network pharmacies, but be aware that your copay amounts will be higher than
those at
Preferred retail pharmacies.  Your benefits at non-preferred retail pharmacies include:

30 Day Supply
Minimum of $5 co-pay for generics or  15% of the approved cost
Minimum of $15 co-pay for preferred brand medications or 25% of the approved cost
Minimum of $40 co-pay for non-preferred brand medications or 50% of the approved cost
Refer to the section below on Prescription Maximum Out-of-Pocket Expenses.
Mail Order Benefit

You can use mail order services offered through Prescription Solutions to fill your prescriptions. Go to the Prescription
Solutions
Website for details. Your mail order benefits include:

Up to 90 Day Supply
Minimum of $12 co-pay for generics or 15% of the approved cost
Minimum of $38 co-pay for preferred brand medications or 25% of the approved cost
Minimum of $75 co-pay for non-preferred brand medications or 40% of the approved cost
Over-the-Counter Drug Benefit (OTC)

A 30-day supply of the following non-prescription allergy, eye, and stomach acid suppressant medications is covered as
an over-the-counter prescription benefit:

                            













The medications listed above will be provided free-of-charge when filled at a Preferred Network Pharmacy. A $5 co-pay
will apply when the prescription for the OTC drug is filled at a Non-Preferred Network Pharmacy.

You must obtain a prescription from your physician for the medications to be covered. The prescription must state “OTC.”
Oral Allergy Medications
 Ocular Eye Medications
 Stomach Acid Suppression
Alavert
 Alaway
 Axid
Alavert D
 Zaditor
 Pepcid
Claritin
   Prilosec
Claritin D
   Tagament
Zyrtec
   Zantec
Zyrtec D
    
Prescription Maximum Out-of-Pocket Expense

  • Only eligible prescription co-pay or co-insurance will apply to the maximum out-of-pocket expenses.  Specialty
    Pharmacy, excess of Quantity Limits, Non Prior Authorization Approval, OTC,  Plan Limitation and Exclusions are not
    counted toward the Maximum Out-of-Pocket Expense.
  • The maximum out of pocket expense per prescription is $100 retail and $300 mail order.*
  • Annual maximum prescription out of pocket expense is $1,400 per member and $2,800 per family.*

*Maximum out of Pocket Expenses can be adjusted annually by Board of County Commissioners,  refer to the annual Open
Enrollment  Handbook for current values.
Prior Authorizations and Other Limitations

The computer software used by the Pharmacy Benefit Manager will evaluate the member’s medication profile and
determine whether any limitations apply.  It will send a message back to the dispensing pharmacist with information
regarding any limitations that have been applied to the prescription.  The pharmacist should supply this information to you.

Certain medications are subject to restrictions on their use.  The most common restrictions are quantity limitations, age
limitations, prior use of preferred medications, step therapy, prior authorizations and gender.

In the case of Prior Authorizations, the member’s physician is responsible for contacting the Manatee Clinical Pharmacist by
phone, fax or email to provide the information required to complete the authorization.  This process is intended to ensure
the safe and appropriate use of the desired medication. Note other important information about prior authorizations and
other limitations.

Prior Authorizations may take up to 72 hours or longer depending on response time from the prescribing physician.
Call your Pharmacy Advocate for more information on necessary Prior Authorizations, Step Therapy, and Plan Limitations.
Early refill due to vacation or business travel is available.  Contact the Manatee Service Center at (941) 748-4501 x6412.