Ascension's prescription drug plan is automatically included with your SmartHealth insurance coverage. SmartHealth pharmacy benefits have two support components. Ascension Rx and Cigna (MaxorPlus will replace Cigna in 2024).
Beginning January 1, 2024, our pharmacy benefit manager (PBM) will shift from Cigna to MaxorPlus. MaxorPlus has over 29 years of experience and will offer new online tools, as well as, an award winning customer service team that will be available for 24/7/365 support. More information will be provided during the annual benefits open enrollment in October.
A new resource that will be available to SmartHealth members will include the Drug Search tool. This tool will allow members to search medications to determine the formulary tier, drug class coverage, and if a prior authorization is required.
MaxorPlus' award-winning customer service Call Center support will be available beginning October 1, 2023 to help answer questions and provide additional information on the 2024 pharmacy benefit, including how to locate a participating in-network pharmacy.
Ascension Rx continues to be a benefit for SmartHealth members and is the preferred pharmacy for specialty and maintenance medications. Ascension Rx offers home delivery services on certain maintenance medications in 90-day supplies. Outpatient specialty prescription medications must be filled by Ascension Rx Specialty Pharmacy to avoid paying the full out-of-pocket cost. For more information on how to enroll or find pharmacies with Ascension Rx, visit click here, call 833-MEDS-ARX (633-7279) Monday - Friday, 8:00 a.m. to 5:00 p.m. CST.
Important pharmacy benefit and ID card information
A new pharmacy ID card will be sent to you for Cigna's drug plan in 2023. Please note that this card is different from your medical card. To fill prescriptions, you must use your prescription ID card.
If you haven’t received your new card by December 31, 2022 and need prescriptions filled, you can continue to use your old card or download the SmartHealth app to access a digital copy of your card.
Weight Loss Drugs: Benefits Exclusion 7/1/23
As part of our standard practice to continually review the safety, long-term outcomes, national coverage benchmarks, and cost-effectiveness of covered medications for all SmartHealth plan members, we recently evaluated weight loss drugs across the SmartHealth membership. Following this careful review, SmartHealth determined that weight loss and anti-obesity drugs will no longer be covered as part of its pharmacy benefit effective on July 1, 2023. These weight loss drugs will be excluded from your Rx benefit. However, this does not affect your access to weight loss services provided through clinics or provider offices.
The weight loss “GLP1” medications, Wegovy and Saxenda are excluded. The anti-obesity medications: Adipex, Alli, Benzphetamine, Contrave, Diethylpropion, Imcivree, Lomaira, Orlistat, Phendimetrazine, Phentermine, Plenity, Qsymia, Resveratrol, and Xenical are excluded. This exclusion will also apply to new weight loss drugs that become available in the future.
Effective 7/1/23, prescriptions written for any of the medications or medication classes listed above, will
require the member to pay directly for the medication. These costs are not applied to the member's annual deductible, nor annual out-of-pocket expense.
There may be patient assistance programs offered by drug manufacturers for some of the weight-loss drugs being excluded. A listing of these programs can be found via this link. These assistance programs may help you with your monthly costs of these medications. Please contact the manufacturer directly to discuss this option. In addition, please reach out to your provider to review options for successful long-term weight loss.
Pharmacy out-of-pocket costs
Benefits exclusion 2023
Paying directly for over-the-counter (OTC) versions of some heartburn, stomach acid, and allergy medications generally costs less than the set copay amount in our prescription plan, so these prescription medications will not be covered in 2023. You can use pre-tax dollars from your health spending account to cover these expenses.
Proton Pump Inhibitors (e.g. Prilosec, Prevacid, Protonix, Dexilant, etc) and H2 Blockers (e.g. Pepcid, Zantac, Tagamet) used to treat heartburn, stomach ulcer, or stomach acid conditions are excluded. Oral 2nd generation allergy, eye allergy, and nasal allergy medications (e.g. Claritin, Clarinex, Zyrtec, Allegra, Pataday, Flonase, Nasonex, etc) are excluded.
Effective 1/1/23, for prescriptions written for any of the medications or medication classes listed above, this will require the member to pay directly for the medication. These costs are not applied to annual deductible, nor annual out-of-pocket expense. Ascension Rx is offering a discount on 90-day supplies of these medications. For additional details, call 833-Meds-ARx (633-7279).
Make the switch to Ascension Rx - get maintenance and specialty medications delivered to your door
Ascension Rx is the preferred pharmacy for SmartHealth members. To learn more, visit the Ascension Rx page.
Please note: For outpatient specialty medications and flex copay drugs, Ascension Rx Specialty Pharmacy is the covered pharmacy for SmartHealth members.
|Important pharmacy documents||Description|
|Formulary list||Covered medications|
|2023 formulary changes|
|Glossary of terms|
|Maintenance medications||Maintenance medications are medications taken at home on a consistent schedule to treat chronic or long-term conditions. This may include oral, injectable, inhaled, ophthalmic and topical medications. Specialty medications are not considered maintenance medications within your pharmacy benefit. These two classifications have different definitions and requirements within SmartHealth.|
|No cost (zero copay) preventative list (PPACA)||Medications available at no cost to members under Patient Protection and Affordable Care Act (PPACA).|
|Preventative medication drug list||Preventive medications are used to help avoid disease and maintain health. For those members on a high deductible health plan (HDHP), before the deductible has been met, these medications will only be subject to copay/coinsurance and still apply towards out-of-pocket max. If your medication is not a maintenance medication on this list, continue to fill it at your local pharmacy.|
|Ascension Rx pharmacies||Click here to find an Ascension Rx pharmacy.|
|Ascension Rx exclusive specialty drug list||A specialty medication is considered a high-cost drug used to treat complex conditions. These drugs are available from your pharmacy benefits, and are usually self-administered. Specialty medications are prescription drugs that are filled by a specialty pharmacy because they have requirements that can only be fulfilled within our Exclusive Specialty Pharmacy Network. Specialty medications meet or exceed a cost of $830 for a 30 days supply, require special handling, require additional patient education, and/or require clinical pharmacy intervention to ensure safe use of the specialty drug.
Specialty medications must be filled within our Exclusive Ascension Specialty Pharmacy network. Some medications may be subject to participation in the Flexible Copay program.*Information on the Flexible Copay program appears below on this website.
|Manual claim form||This claim form can be used to request reimbursement of covered expenses paid out of pocket.|
|Continuous glucose monitors||Continuous glucose monitors (CGM) are important tools for tracking and managing diabetes. Your plan offers coverage for two CGM sensors under your pharmacy benefit: the Dexcom G6®and Abbott FreeStyle Libre.|
|Diabetic benefit||Ascension preferred diabetic medications and supplies receive a reduced copay when filled at an ARx pharmacy.
Medications: Novolog (additional may be added)
Supplies: T1 (preferred generic) & T2 (preferred brand)
Continuous Glucose Monitors: T2 (preferred brand)
SmartHealth Flexible Copay program
In 2023, the cost share for some specialty medications may increase, which could result in higher out-of-pocket costs. Because Smart Health is committed to ensuring our members receive the lowest out-of-pocket cost on these high-cost medications, we are continuing the SmartHealth Flexible Copay program. This benefit program works with drug manufacturer’s copay assistance programs to provide the lowest out-of-pocket cost to SmartHealth members who need these medications.
If you have a high copay and would like to find out if you are eligible, call the SmartHealth Flexible Copay program at 1-833-980-2352 and select option 7 to get started. Click here to view FAQs.
Provider administered specialty medications or infusion therapies
(Your provider or physician's office must submit the prior authorization)
All physician-administered specialty medications or infusion therapies are subject to precertification notification or prior authorization (PA) approval. For a product list with current requirements, please see the medical benefit drug list. The file includes two lists:
1. No Precert, No PA Required: List of products that do not require a precertification or a prior authorization.
2. PA required: List of products requiring PA - includes a link using Brand Name to prior authorization clinical criteria for use documents.
To submit a precertification notification or prior authorization request for a physician-administered product or infusion therapy:
1. Download the form: Medical benefit drug precertification notification and PA form.
3. Submit the completed and signed form: