Your Prescription Drug Coverage at a Glance
Your Pharmacy Options
Mashantucket Pharmacy (aka: Main or Reservation Pharmacy)
The Mashantucket Pharmacy is located at One Annie George Drive, Building 1 on the Mashantucket Pequot Tribal Nation.
The Mashantucket Pharmacy hours of operation are:
Monday – Friday from 8:30 a.m. to 7:30 p.m.
Saturday from 9:00 a.m. to 12:00 p.m. (noon)
Closed Sundays and some holidays.
Foxwoods Satellite Pharmacy
PRxN also operates a satellite distribution pharmacy located in the “back of house” in the Great Cedar area on the Foxwoods Casino property. This is a limited service location that ONLY accepts and dispenses prescriptions that are filled and verified at the Mashantucket Pharmacy. The satellite is staffed by PRxN pharmacy technicians.
The Foxwoods Satellite Pharmacy hours of operation are:
Monday through Friday from 7:30 a.m. to 4:30 p.m.
Remote Distribution
Prescriptions that are not considered urgent or acute (such as antibiotics, pain medications for an injury, discharge medications from a hospital or ER) and generally are used for long term (maintenance medications used for longer than thirty days) and those medications used on an “as needed” basis should be processed by PRxN. If you are unable to visit one of the physical pharmacy locations, it may be appropriate for you to use Remote Distribution service. Available at no cost, prescriptions will be sent directly to your home or address that you designate.
Prescriptions should be ordered with some lead time, so please plan ahead for up to a seven to ten-day delivery cycle. Most prescriptions turn around from PRxN within 3-4 days but PRxN may need to contact your provider.
Prescriptions may be ordered up to 2 weeks in advance so please plan ahead when ordering medications to be delivered through the mail, to allow for some cushion and ensure that you have an adequate supply of medication on hand.
Retail Pharmacy Network
PRxN has also established a nationwide network of over 65,000 participating retail pharmacies for plan members to use for acute medication needs and/or when they are unable to access PRxN due to location or timing.
This access to a retail pharmacy network is particularly convenient when you are out of town, after normal operating hours or on a Sunday or holiday when the Mashantucket Pharmacy may be closed.
Please remember:
- Members will have a co-pay when using a network pharmacy and will be limited to a 30 day supply
- Also, NO over-the-counter (OTC) products are covered under the plan at retail network pharmacies
- Some OTC medications are covered on Your Plan at PRxN
Non-Network Pharmacy
A non-network pharmacy is one that does NOT participate as one of the pharmacies in the PRxN network. When required to use a non-network pharmacy, members are required to pre-pay the entire cost of the medication at the time of service. Members may submit these claims to PRxN for reimbursement.
Co-insurance / Copayments
Co-insurance and copayments (co-pays) refer to the amount you are expected to pay for a prescription at the time you get your prescription filled. Prescription medication co-pays are dependent upon the particular medication and which point of service (pharmacy) you choose to use. The following chart describes the different costs associated with the pharmacy you choose based on your Medical Plan.
Special Situations
Requests for early refill or replacement medications that have been lost, stolen, damaged or spilled are subject to pharmacist and administration review and approval. Plan restricts special situation overrides to one (1) occurrence per year.
PRxN Drug List (PDL)
The PRxN Drug List is a guide within select therapeutic categories for clients, plan members and health care providers. Generics should be considered as the first line of prescribing. If there is no generic available, there may be more than one brand-name medicine to treat a condition. Preferred brand-name medicines are listed to help identify products that are clinically appropriate and cost-effective.
To view or obtain a copy the PDL, go to www.prxn.com/PDL, refer to the PRxN on Foxnet website, stop by any PRxN location or contact a PRxN Customer Service Representative at 1-800-342-5779.
PRxN Over-the-Counter (OTC) Medications
PRxN offers all team members (even those who do not elect to enroll in the Medical Plan) access to reduced pricing on many of the most popular over-the-counter (OTC) medications. These items are available for purchase at both the main Mashantucket and Foxwoods Satellite locations. Compare to retail!
Getting Your Prescription to PRxN
Prescriptions may be brought/sent to either Pharmacy location in several different ways:
- You may bring them to either Pharmacy in person;
- You may mail them to the Mashantucket Pharmacy for processing by requesting a pre-addressed business reply envelope from Customer Service; or
- Your healthcare provider can telephone, fax or electronically prescribe (e-Rx) prescriptions directly to the Pharmacy.
- You can also order your refills through the telephone (800-342-5779) or over the internet at www.prxn.com/forms/refillPrescription.aspx.
You may request that your prescriptions be picked up at the Mashantucket Pharmacy, the Foxwoods Satellite Pharmacy, or delivered by Remote Distribution (U.S. Mail or FedEx delivery, as appropriate)
Prescription Management Programs
Generic Medication Preference
The use of generic medications is preferred under the Pequot Open Plan. To gain FDA approval, generic medicines must prove they are exactly like brand name equivalents in regards to safety, identical active ingredients, performance (how it works in the body), strength (e.g., 10mg, 20mg), and dosage form (tablet, capsule, liquid, cream, etc.).
Generics are less expensive due to the fact that the research and development are already done! Generic manufacturers do not have to spend the hundreds of millions of dollars it takes to complete research and development on the new original medicine. The brand manufacturers make the investment, along with the millions of dollars needed to market and advertise the new medicine. Therefore, it costs the generic manufacturer less to develop the same medicine. The savings are passed on to the plan and to you.
The FDA puts each generic medicine through a rigorous review process ensuring that generics are as safe and effective as the original brand name medicine. Both brand name and generic drug facilities must meet the same good manufacturing practice standards. The FDA inspects more than 3,500 pharmaceutical facilities each year to monitor how the medicines are made, processed, tested, packaged, and labeled.
Generic medications are available through PRxN with ZERO co-pay for up to a 90-day supply.
Mandatory Generic Program
The use of generic medications is mandatory under the Pequot Open and PPO Choice plan. If you require a brand name medication under this plan when a generic equivalent is available, you will be responsible for the full cost of the brand name prescription. To gain FDA approval, generic medicines must prove they are exactly like brand name equivalents in regards to safety, identical active ingredients, performance (how it works in the body), strength (e.g., 10mg, 20mg), and dosage form (tablet, capsule, liquid, cream, etc.).
Generics are less expensive due to the fact that the research and development are already done! Generic manufacturers do not have to spend the hundreds of millions of dollars it takes to complete research and development on the new original medicine. The brand manufacturers make the investment, along with the millions of dollars needed to market and advertise the new medicine. Therefore, it costs the generic manufacturer less to develop the same medicine. The savings are passed on to the plan and to you.
The FDA puts each generic medicine through a rigorous review process ensuring that generics are as safe and effective as the original brand name medicine. Both brand name and generic drug facilities must meet the same good manufacturing practice standards. The FDA inspects more than 3,500 pharmaceutical facilities each year to monitor how the medicines are made, processed, tested, packaged, and labeled.
Generic medications are available through PRxN with ZERO co-pay for up to a 90-day supply.
Mandatory Mail Service
After you have had three (3) fills of a particular maintenance medication at a retail pharmacy, all future prescription refills for that medication must be obtained through PRxN mail-service pharmacy.
Your plan allows for three (3) retail fills to ensure that you can tolerate the medication or that you do not experience any side effects that would cause you to stop taking the medication. This retail benefit ensures that you are having a positive therapeutic response/outcome to the particular medication prior to obtaining a larger (“maintenance”) supply. Once you are “stable” on the medication, all future refills at a retail pharmacy would be denied and you would need to obtain your medication through PRxN mail-service pharmacy.
The PRxN mail-service pharmacy is your least expensive option. Plus, PRxN offers several other advantages. It’s safe, convenient and easy to use even when you’re traveling or if you move.
You may receive up to a 90-day supply for most medications through the mail-service pharmacy. This 90-day supply minimizes your out-of-pocket costs and the medications will be delivered directly to your home or office.
Step Therapy
Step Therapy is a program that ensures that plan participants use clinically appropriate drugs in a cost effective manner. Step Therapy programs are developed based on current medical findings, FDA approved drug labeling, and medication costs. In general, Step Therapy is applied to therapeutic categories that have multiple agents, comparable therapeutic efficacy and utilization and those that have generic alternatives. Generic drugs are commonly prescribed as the “first-line” agent due to their established safety and efficacy for treating a given condition, and are typically less expensive than branded medications.
Select branded medications may not be covered unless a plan participant tries and fails an alternate “first line” agent(s).
When you present a prescription for a medication that is under a Step Therapy program, the dispensing pharmacy receives an electronic message informing the pharmacist that the medication is under Step Therapy. If PRxN is the pharmacy processing this prescription, PRxN will initiate contacting the physician to make them aware of the Step Therapy. If you are using a retail network pharmacy, the pharmacist would need to consult with the physician and PRxN to select the medication that is covered under the Step Therapy.
Occasionally, the “first line” Step Therapy agent may not be the ideal medication to treat the condition. Under these circumstances, or if you meet certain medical exemption criteria, PRxN may authorize an alternative. If these criteria for an exemption are not met, you and the prescribing physician will receive notification that the prescription claim has been denied and outline the steps to submit an appeal.
Managed Drug/Dispensing Limitations (MDL)
The MDL program is a mechanism used to manage drug use and promote safe and clinically-appropriate drug use within specific therapeutic classes of medications. MDLs ensure that you still receive your medication in an amount that is approved by the plan for a specific length of time.
MDLs help to prevent overuse and/or “stockpiling” of medications. Under an MDL program, there is a limit on the amount and/or the day supply of selected medication(s) that may be obtained at the time of dispensing. MDL programs are used to manage drug costs on specific medications without eliminating coverage.
If you present a prescription for a quantity above the maximum threshold, the prescription will reject stating “Excessive Quantity”. The pharmacist should discuss the quantity covered by the plan. Additionally, if you attempt to refill a medication too soon, the dispensing pharmacist will be alerted of a possible overuse/abuse situation.
If you exceed the quantity limits on certain medications in the MDL program, your prescribing physician does have the option to apply for an MDL Prior Authorization review. PRxN staff would work with the prescribing physician to determine if this increased quantity desired is appropriate and discuss other options for treatment/evaluation that could be of benefit. If an override authorization is approved, you will be allowed to fill for a quantity greater than the MDL limit and only pay your co-pay.
If you still desire a quantity above this established threshold after the MDL Prior Authorization is disapproved, you become solely responsible for the cost above the threshold (100% co-payment).
Specialty Guideline Management (SGM)
This program supports safe, clinically appropriate and cost-effective use of specialty/biotech medications. Specialty/biotech medications are injectable, infused, or oral therapies that typically treat genetic or rare chronic conditions; require close monitoring of a patient’s therapy to adjust dosing and ensure that outcomes are being met; require special storage, handling and/or administration; and require extensive patient-specific education and training to ensure appropriate use.
Specialty/biotech medications are required to be filled through PRxN exclusive specialty pharmacy partner. To determine which medications are considered Specialty/biotech, members are encouraged to call the PRxN Pharmacy Benefits department at 1-888-779-6638.
Limitations on Coverage
Prescription drug benefits are subject to the same exclusions as the MPTN Medical Plan. See “What’s Not Covered” under the Your Medical Plan section.
Most medications are covered under the Medical Plan. However, there are some medications with quantity restrictions as noted above. For a complete list of restrictions and limitations, you should contact PRxN Pharmacy Benefits department at 1-888-779-6638.