Out-of-Pocket Maximum
An out-of-pocket maximum is the maximum amount you can be subject to pay for your pharmacy benefit plan in a plan year. Copayments paid towards your prescription medication contribute to your out-of-pocket maximum. After you reach the maximum defined by your pharmacy benefit plan, the plan will pay 100% for any covered service, and you will not have to pay any additional money out of pocket.
Example: If your out-of-pocket maximum is $3,000 on your pharmacy benefit plan, you can be subject to pay up to $3,000 for services and prescriptions through your copayment. Once you spend $3,000, the pharmacy benefit offered by your pharmacy benefit plan will cover any extra services, prescriptions, and costs for the rest of the year.
Deductible
A deductible is the amount you must pay out of pocket for services before the pharmacy benefit plan starts to pay.
Example: If your pharmacy benefit plan has a $1,500 deductible, you must pay the first $1,500 out of pocket before the pharmacy benefit plan starts covering any costs. Depending on the plan design, you may still have to pay copay amounts for additional services.
As part of the InScript clinical program, members on highly complex medications may be required to adhere to InScript’s Site of Care Management program. The Site of Care Management program ensures that you are being clinically managed by the appropriate medical provider to ensure the most optimal clinical outcome. If this program is required for prescription coverage, you will need to obtain a second opinion from our network approved provider. When your prescription requires you to participate in the Site of Care Management program, you will be contacted by the InScript Member Services team.
As part of the InScript clinical program, members on highly complex medications may be required to adhere to InScript’s Medication Therapy Management (MTM) program. The MTM program is a pharmacist led program to optimize therapeutic outcomes, clinical quality, and ensure medical appropriateness. When your prescription requires you to participate in the MTM program, you will be contacted by the InScript Member Services team.
Impacted Medications:
- Bydureon
- Byetta
- Mounjaro
- Ozempic
- Rybelsus
- Saxenda
- Soliqua
- Trulicity
- Victoza
- Wegovy
- Zepbound
Your BILH health plan administered by InscriptRx has adopted unique coverage criteria for glucagon-like peptide-1 (GLP-1) medications. Plan members using GLP-1s for weight loss specifically are required to complete a Medication Therapy Management (MTM) virtual visit with the BILH Weight Loss Management Clinic.
To assist with this process, the BILH Weight Management Team will call to schedule an appointment or they can be reached at 781-352-6551 to answer questions or to proactively schedule your visit.
What to expect during an MTM appointment: A weight loss-specialized pharmacist will assess and evaluate your clinical condition, review any side effects, answer any questions you have about your medications, and discuss lifestyle modifications to enhance your outcomes.
For all indications for GLP-1s, please use this form to submit a prior authorization for the product.
If you have forgotten your InScript ID card and paid out-of-pocket for your prescription, you may be able to be reimbursed by filling out this form. Please note that your medication must be covered and filled at an appropriate in-network pharmacy.
The BILH Copay Assistance Program helps reduce out-of pocket costs incurred by members of our employer-sponsored health insurance plans for certain high-cost medications, called “specialty medications”. You and/or your covered dependents will be contacted if you take a qualifying specialty medication. You can also call 617-589-1162 to confirm if your specialty medication is eligible for financial support through the program.
A prior authorization (PA) is a clinical program to ensure safety and medical necessity. If you are prescribed a drug that requires a PA, please have your provider fill out the general PA form.
As part of the InscriptRx program, weight loss GLP-1s are required to follow certain clinical criteria. If you are prescribed a GLP-1 for any indication, please have your provider use this form to submit a PA for a product.
Please visit the BILH Benefits Central website to learn more about your prescription benefits.
As part of the InScript clinical program, members on highly complex medications may be required to adhere to InScript’s Site of Care Management program. The Site of Care Management program ensures that you are being clinically managed by the appropriate medical provider to ensure the most optimal clinical outcome. If this program is required for prescription coverage, you will need to obtain a second opinion from our network approved provider. When your prescription requires you to participate in the Site of Care Management program, you will be contacted by the InScript Member Services team.
