Group Pharmacy Benefit Information

Mail Order Pharmacy

Members taking prescriptions for a long-term condition may be able to get their drugs through the mail if their pharmacy benefit includes mail order.

Medica offers pharmacy mail order through Express Scripts^® Pharmacy. You'll receive a 90-day supply of their medication through the mail, with no shipping or handling fees.¹

Obtaining a 90-day prescription supply is not only convenient, but can result in cost savings for many members, particularly those taking brand-name medications. Those taking generics should also investigate their options since many retail pharmacies will also offer discounts for a 90-day supply of generic medications.

Members who take maintenance medications may receive up to a 90-day supply from a participating pharmacy by paying three copays at once.

Important information about 90-day refill options for the VantagePlus with Medica plan.

Step Therapy is a program focused on members receiving appropriate and affordable drug treatments. This program is used for conditions with many treatment options and requires members to receive preferred drugs (Step 1 drugs) as the first line of therapy.

Step 1 drugs are effective, but more affordable. When appropriate, a more costly (Step 2) medication can be authorized if the Step 1 prescription is not effective in treating the condition.

Conditions that can be treated using many safe, effective medications may be eligible for the Step Therapy program. All Step Therapy programs have been reviewed and approved by our Pharmacy and Therapeutics Committee, a panel of independent practicing physicians and pharmacists.

Specialty drugs are high-technology, high cost, oral or injectable drugs used for the treatment of certain diseases that require complex therapies. Many specialty drugs require special handling and in most cases are prescribed by a specialist.

Our designated specialty pharmacy allows members the convenience of home delivery, or the option to pick up most prescriptions at one of their local sites. Members will be provided with resources and support to help them achieve the best results from prescribed therapy.

An experienced care team of pharmacists and nurses is available to help members obtain medication, answer questions, assist in managing side effects, and lend overall support.

Note: Members should refer to their coverage documents to determine their specific benefit levels for specialty drugs. If a member has questions about their specialty drug coverage, they should call the Medica Customer Service number on the back of their ID card.

Specialty Drug Vendor

Accredo Specialty Pharmacy is our preferred Specialty Drug Program vendor.

Accredo Customer Service representatives are available Monday through Friday 7 a.m. – 10 p.m. and Saturday 7 a.m. – 4 p.m. Central

Phone: 1-866-544-6817 (toll-free) (TTY: 711)

A brand-name drug is protected by a patent for a certain amount of time. That means only one manufacturer can make the drug during that time. Once the patent expires, generic versions of the drug are often introduced.

Generic drugs have the same active ingredients as their brand-name counterpart and must meet the same quality standards as brand-name drugs, but are generally less expensive.

Both brand-name and generic drugs are regulated by the Food and Drug Administration (FDA).

Yes. A team of physicians and pharmacists regularly reviews new and existing drugs to be sure the drug list continues to meet our members' and providers' needs. Drugs may be added to the list at any time during the year; however, Medica strives to limit removing drugs to no more than twice a year.

If a generic equivalent becomes available for a brand-name medication on our drug list, we may update the list to only include the generic as the preferred drug. If a change to the list affects a drug you are taking, we’ll send you a letter telling you about the change.

Specialty drugs are used to treat certain complex health problems. These drugs tend to be very expensive and may need special handling and monitoring. For most specialty medications, you'll use Accredo Specialty Pharmacy to fill your prescriptions.*

*Or through the designated specialty pharmacy vendor if it's a limited distribution drug.

Step Therapy is a program focused on using cost-effective prescription drugs as first-line treatment when appropriate. The program is used for certain conditions where there are many treatment options available. Drugs that require Step Therapy are noted on the drug list. Some drugs may also require prior authorization.

In Step Therapy, you try the Step 1 preferred drug or drugs first. Step 1 drugs are cost efficient and effective options. If the Step 1 drug isn't effective, you can then try the Step 2 drug. In some cases, you may need to try more than one Step 1 drug before trying a Step 2 drug.

Step Therapy applies to all members, regardless of their plan type. That means that if you don't try the Step 1 drug or drugs first, then a Step 2 drug won’t be covered. Your doctor may request an exception if your current drug is the best clinical option for you. If authorization is given, we’ll continue coverage of your current drug. If the request is denied, you may appeal the decision.

Prior Authorization is approval given by Medica for coverage of a certain medication. Medications that require Prior Authorization are noted on the drug list with a "PA" next to the drug name. As a provider in the Medica network, your doctor will know how to request Prior Authorization.

Your doctor can request an exception to the drug list by visiting Medica.com/RxPA.

Yes. If your exception request is denied, Medica will send you a letter explaining your right to appeal and the process for the appeal. You can also call Medica Customer Service at the number on the back of your Medica ID card and tell the representative that you wish to appeal a decision.