Medical: Prescription Coverage Details

Incident Prescriptions

  • Incident = a medical diagnosis (such as an ear infection) or event (such as a broken arm) or check-up (such as a woman well check with labs and imaging)
  • Incident total = added total of all the pre-discount costs of all bills (doctor visits, prescriptions, lab work, imaging, therapy, etc.) associated with this incident
  • Examples include Antibiotics, Tamiflu, Valium, Soolantra, etc.

If the prescription is part of an incident with an  incident total under $1,000, then you use your EBC card to pay for it.

If the prescription is part of an incident with an  incident total over $1,000, then you use your personal credit card to pay for it.  You will then include the prescription in the bills you submit to CHM for full reimbursement.

  • If, as part of an incident, you have been prescribed a new drug that will be part of ongoing, maintenance treatment, then the first three months of the prescription can be reimbursed by CHM as part of the incident.  Starting the fourth month, the prescription is considered a maintenance prescription and is now covered by the Austin Stone Component of the Heath and Wellness Plan.

Maintenance / Ongoing Prescriptions

  • Examples include Vyvanse, Synthriod, Lipitor, Insulin, Birth Control, etc,

If the prescription is an ongoing, maintenance prescription, then your coverage for it is provided by the Austin Stone Component of the Health and Wellness Plan.  You will start by using your EBC/HRA card to pay for it,  regardless of price.  Maintenance prescriptions are not covered by CHM even if they are over $1,000.  

If the cost of the medication is significant (meaning it will use up all of your HRA by the end of the year), please contact Denise.  We have a program that may be able to help!

Allergy Shots

Allergy shots and related visits may be eligible for reimbursement through CHM if they reach the threshold of $1000 prediscount.

From the CHM Guidelines: "Immunotherapy or allergy shots are eligible during the build-up or desensitization phase, usually a period of six to nine months. Once injections transition to monthly administration, immunotherapy enters the maintenance phase, and the treatment is no longer eligible. Medical records may be necessary to make sure your treatment plan meets eligible criteria."

If submitted to CHM and the six to nine months desensitization period finishes, then allergy shots become a maintenance medication and can be submitted to EBC.

When you are at the doctor and getting a prescription, the doctor will usually ask you which pharmacy you'd like to send your prescription to.

Stop for a moment and use these tools to get great discounts and coupons for prescriptions:

GoodRx and RxSaver Apps

Open up the GoodRx app and RxSaver Apps (download for  Apple or Android) to enter in the medicine your doctor is prescribing.  You can find coupons and discounts for your medicines and find which pharmacy is selling them at the cheapest price. Ask the doctor to send the prescription to the pharmacy of your choice.  When you're at the pharmacy, show the appropriate app to your pharmacist to get the discount!

Here is what Good Rx looks like:

Here is what RxSaver looks like:

Orphan Drug Coverage

What are Orphan Drugs?

  • Orphan drugs may be defined as: Drugs that are not developed by the pharmaceutical industry for economic reasons but which respond to public health need.
  • 'Orphan drugs' are intended to treat diseases so rare that sponsors are reluctant to develop them under usual marketing conditions.
  • The process from the discovery of a new molecule to its marketing is long (10 years in average), expensive, and very uncertain. Developing a drug intended to treat a rare disease does not allow the recovery of the capital invested for its research.
  • You can see a list of orphan drugs here: Orphan Drug Database

Coverage for Orphan Drugs is limited by the Austin Stone Health and Wellness Plan.

  • When first prescribed, an orphan drug can be covered by CHM for the first 3 months of the prescription.
  • After the first three months, there is no longer coverage for the orphan drug by the Austin Stone Health and Wellness Plan.
    • At this point, you will need to work with the drug manufacturer Patient Assistance Program.  
    • Most of the time, you are able to get the drug at no cost through the PAP because your "insurance" or health plan does NOT provide any coverage for the drug.
    • Please reach out to Denise with any questions (denise@austinstone.org)