Pharmacy Benefits through Prime Therapeutics

Pharmacy Benefits Managers

Prime Therapeutics LLC is the pharmacy benefits manager and Fairview Specialty Pharmacy is the exclusive provider of most specialty medications.

Automatic Enrollment

Your enrollment in the Prime Therapeutics and Fairview Specialty Pharmacy prescription drug program is automatic when you elect a medical plan option with Medica. You will receive a separate member identification card from Prime Therapeutics.

Jump to:

• Benefit Levels
• Drug Formulary
• Pharmacy Network
• Specialty Medications
• Medication Therapy Management (MTM)

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Benefit Levels

Prime Therapeutics covers a 30-day supply of prescription medications (including insulin) through network pharmacies at the following levels:

• $0 copayment for select preventive medications specified in the Affordable Care Act, including contraceptives in the Generic Plus category. Medica HSA covers these medications at 100%.
• $10 copayment for Generic Plus (Tier 1) medications, which covers all generic drugs and certain preferred brand drugs for which there is no generic therapeutic equivalent
• $30 copayment for Brand Formulary medications (Tier 2, includes all other brand name medications listed on the formulary)
• $60 copayment for Non-Formulary medications (Tier 3, includes all covered brand name medications not listed on the formulary)

The annual out-of-pocket maximum is $750 per person and $1,500 per family.

For the Medica HSA plan, your prescriptions can be covered first under the account and then the annual deductible applies until it is met. After that, the medical plan pays 90 percent of pharmacy expenses in the HSA.

Drug Formulary

The drug formulary through Prime Therapeutics provides you with safe, effective, high-quality, cost-effective medications to ensure the best medical results while also reducing the overall costs for providing prescription benefits. Prime Therapeutics has a strong emphasis on the use of generic medications to help control the cost of prescription drugs. Generic versions of brand name medications are clinically proven to be just as effective as their brand name counterparts at a fraction of the cost. The University of Minnesota UPlan Formulary (pdf) lists the medications that are covered by the program.

Pharmacy Network

Prime Therapeutics has a broad Minnesota and national retail pharmacy network that includes popular chains, clinic and hospital pharmacies, independent pharmacies, and a home delivery mail service pharmacy. Fairview Specialty Pharmacy provides home delivery or pick-up service of specialty drugs at Fairview clinic/hospital retail pharmacies and at SMDC and St, Luke's Duluth.

Specialty Medications

Specialty drugs are generally prescribed for people with complex or ongoing medical conditions. Specialty drugs are provided though Fairview Specialty Pharmacy because they are high cost and have unique storage or shipment requirements. Members using specialty medications need additional education and support from a health care professional due to the complexity of use and the potential for some serious side effects.

Medication Therapy Management (MTM)

Medication Therapy Management is a patient care service offered to eligible UPlan members in which you have face-to-face meetings with a specially trained pharmacist who can help you improve the quality and effectiveness of your medication therapy program.