Pharmacy Benefits Q&A

This information is intended to provide general guidance for members’ common questions about MUST. The Summary Plan Description document, related amendments, and Schedule of Medical Benefits may supersede this general information for specific eligibility and benefit questions.

1. Do all MUST plans have a pharmacy benefit?
All plans except the Basic Plan and the Health Savings Account (HSA) qualified plan have a prescription (pharmacy) benefit. Please note:

If you are enrolled in the Basic plan: You pay for your own prescriptions. There is no coverage for prescriptions under the Basic plan; however, you might receive discounted prices at the pharmacy as a MUST member (be sure to show the pharmacist your MUST identification card).
If you are enrolled under the HSA-qualified plan: You pay for your own prescriptions and submit the receipts to the plan. If your medical deductible has not yet been satisfied, they will count toward that deductible. If your medical deductible is satisfied, they will be covered according to the same co-payment percentages as any other medical services.

For other MUST plans (Catastrophic, Comprehensive Major Medical, and Revised Major Medical), the pharmacy plan has a separate deductible and maximum out-of-pocket amount and prescriptions, therefore, do not count toward the medical deductible and out-of-pocket amounts.

2. Is there a separate ID card for the pharmacy benefit?
No; your MUST card includes the information that the pharmacist will need.

3. What should I do if I need to fill a prescription and haven’t yet received my MUST card?
Call MUST Customer Service (1-800-845-7283) to verify that your enrollment forms have been received and processed. If they have, you will be given your group plan number verbally. The pharmacist will usually accept this, but if not, ask him/her to call the number above to verify your eligibility.

4. Can I really save money by filling a 90-day prescription?
Yes; your copayment is usually lower than if you purchased three 30-day prescriptions. Ask your doctor if a 90-day prescription is appropriate for the drugs that you take.

5. Do I have to use a mail-order service to get a 90-day supply?
No; there are several pharmacies that have agreements in place for 90-day fills, including most major chains. A list of pharmacies in your area is available on the Caremark Web site (see the “Pharmacy Plan" link on the MUST home page, under "Quick Links").

6. What should I do if my pharmacist doesn’t bill insurance?
If your pharmacist won’t bill insurance or doesn’t belong to the pharmacy benefit plan’s network, he or she will require full payment at the time of purchase. If your MUST coverage includes a pharmacy benefit plan, you can submit a claim yourself using this form. Be sure to follow all instructions on the form.

7. I have dual pharmacy benefits under both my own policy and my spouse’s policy. How does that work?
With MUST, coordination of benefits for pharmacy claims is handled the same way as coordination of benefits for medical claims. In general, MUST as the secondary plan pays a reduced amount so that the combined amount paid by both plans does not exceed 100% of the allowable charge. Deductibles and co-payments under each plan will also affect your out-of-pocket cost at the pharmacy.

Important note: The Pharmacy Benefit Manager* can process pharmacy claims under the primary coverage only. Therefore, the Pharmacy Reimbursement Form cannot be used to process pharmacy claims under the secondary plan. See the Pharmacy Benefit section of the Summary Plan Description document, under “Primary Coverage Under Another Plan.” This section provides instructions for submitting pharmacy claims to the MUST claims office for processing under the secondary MUST plan.

Tip: Pharmacy receipts sometimes do not show the full retail cost of the drug. This can create problems when trying to process the claim under the secondary plan. Be sure that the pharmacy provides you a receipt that shows the full retail cost, not just the co-payment amount charged under the primary plan.

8. Can I drop only the prescription drug part of my MUST benefits?
No; the prescription drug benefit (if applicable) is integrated with your MUST health plan.