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My.atlanticmedicalimaging.com

ATLANTIC MEDICAL IMAGING
PRESCRIPTION DRUG PLAN INFORMATION
EFFECTIVE 11/1/2013
Welcome to WellNet!
The information below is a general description of your plan benefits and is not meant to be a complete list or complete description of available services. Please contact WellNet at 800-727-1733 with specific questions
about your program.
PRESCRIPTION DRUG COPAYS
MAIL SERVICE
(up to 30 day supply)
(up to 90 day supply)
Over-the-Counter PPI’s & Smoking Cessation HOW THE COPAYS WORK
Your copays are based on the Preferred Drug List. A copy of the formulary list is included with your ID cards.
PROGRAM DETAILS
When you request a brand name drug instead of its generic equivalent, you will be responsible for paying the brand name All diabetic supplies will be covered at no copay; no insulin claim is required The following drugs have quantity limits based on the FDA guidelines • Sleep Aids, such as Ambien and Lunesta limit is 15 quantity per 31 days IMPORTANT – PLEASE READ
The drug listed below requires Prior Authorization by your physician before
THOROUGHLY
they will be dispensed at the pharmacy. Please ensure that your physician has Prior Authorization Program
ADD/Narcolepsy - Adderall/XR, Concerta, Desoxyn, Dexedrine, Dextrostat, Focalin,
Phone: 1-888-413-2723
Metadate CD/ER, Provigil, Ritalin/LA, Strattera, Xyrem; Anemia - Aranesp, Epogen,
Procrit; Arthritis - Arava, Humira, Kineret; Asthma - Xolair; Cancer - Gleevec, Iressa, Tarceva,
Thalomid; Cox IIs - Celebrex; Gaucher Disease - Zavesca; Migraine - Amerge, Axert, Frova,
Authorization BEFORE you go
Imitrex/NS, Maxalt/MLT, Migranal NS, Relpax, Zomig/ZMT/NS; Multiple Sclerosis - Avonex,
Betaseron, Copaxone, Novantrone, Rebif; Tysabri; PAH - (Tracleer); Ribavirins - Copegus,
Rebetol, Rebetron, Ribasphere; Select Interferons - Infergen, Pegasys, Peg-Intron;
Topical Acne - Atralin, Avita, Retin-A/Micro, Tretinoin, Tretin-X.
SpecialtyRx
Certain chronic and/or genetic conditions require special pharmacy products, Phone: 1-800-237-2767
often in the form of injected or infused medicines. All self-injectable drugs, not including insulins or Epi-Pens, must be filled through the specialty pharmacy. Some examples of specialty medications include: Rheumatoid Arthritis- Enbrel, Humira, Kineret, Remicade; Cancer- Gleevec, Iressa,
Tarceva, Thalomid; Multiple Sclerosis- Avonex, Betaseron, Copaxone, Novantrone,
Rebif, Tysabri; Select Interferons- Infergen, Pegasys
ATLANTIC MEDICAL IMAGING
PRESCRIPTION DRUG PLAN INFORMATION
EFFECTIVE 11/1/2013
MAIL SERVICE: HOW TO GET STARTED WITH MAIL ORDER
The mail service program is not mandatory but is designed to save you time and money on your maintenance
prescriptions by providing home delivery and allowing you to purchase a 90-day supply of medication for a discounted price. Choose one of two easy ways to get started: 1. Ask your doctor to write your prescription for a 3-month supply plus refills. Fill out a mail order form, enclose the prescription(s) and mail it in. 2. Use the FastStart Mail Order program by calling 866-772-9414. Provide the representative with your name, ID, a list of your medications, your doctor’s name and number, and a credit card number. The representative will call your doctor for you to get the prescription started. NOTE: You may wish to call your doctor ahead of time so there is no delay in processing your prescription request.
No matter which method you choose, your first prescription will arrive in approximately 10-14 days. Once your first prescription is ordered, register on www.caremark.com to order refills online.
DRUG COVERAGE
DRUG EXCLUSIONS
covered on this plan:
excluded on this plan:
(drugs that require a prescription by law) (such as wrinkle agents, hair growth agents) • OTC PPI and Smoking Cessation medications YOUR I.D. CARD
DEPENDENT STUDENT STATUS
Your plan provides coverage for dependents up to age 26 CLAIMS AND APPEALS
CLAIMS: If you have paid out of pocket for a prescription and require
reimbursement, please submit your prescription receipts to WellNet, along with your Member ID and Group Number. WellNet will submit the claim on your behalf and get you reimbursed (minus the appropriate copay). Please fax your claims to: Claims Dept. 866-516-1759.
APPEALS: If your prior authorization is not approved, you have the right to file an
appeal. Contact WellNet at 1-800-727-1733 for instructions on how to complete
CAREMARK
IMPORTANT PHONE NUMBERS & ADDRESSES
IMPORTANT PHONE NUMBERS & ADDRESSES
Customer Service: 800-727-1733
Customer Service (24/7): 866-885-4944
FastStart Mail Service: 866-772-9414
Mail Service Inquiries: 800-966-5772
Fax: 866-516-1759
Prior Authorization: 888-413-2723
WellNet Interactive: 877-396-1402
SpecialtyRx: 800-237-2767
Website: www.wellnet.com
Website: www.caremark.com
Address:
Mail Service Address:
57 Street Road, Suite O, Southampton, PA 18966

Source: http://my.atlanticmedicalimaging.com/sites/default/files/enrollment/Forms/RxPlanDescription.pdf

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