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Click here or scroll down to respond to this candidateSimpleScripts Rx PRESCRIPTION SUBSCRIPTION PLAN (ACA/MEC)Pharmacy SUBCRIPTION PLAN Contact SimpleScripts Rx at PHONE NUMBER AVAILABLE or EMAIL AVAILABLE during the hours of 8:Street Address AM and 6:00 PM EST. The web address is www.SimpleScriptsRx.com where you can register and place and renew Mail Order prescriptions. You will need either a written physician prescription or have your doctor call in the prescription.SimpleScripts Rx (Shield PBM) is the administrator of the pharmacy drug plan. You must use a participating pharmacy to fill your prescription. To fill a prescription, you must show the pharmacy your Plan ID card. Member ResponsibilityAll Medications under the ACA/MEC Plan are covered at Street Address %. See formulary for details. Mail Order Drug BenefitThe Mail Order drug benefit is used for member convenience. All medications on the specific formulary can be shipped directly to members home at no charge. Other medications that are not part of the formulary will be offered at a deep discount.Candidate's Name
(1) Read the Drug Formulary to see which drugs are covered.(2) Retail Pharmacies are limited to a 30-day supply. Mail Order drugs are limited to a 90-day supply in most cases. Some medications qualify for a 30 day fill via mail order.(3) In certain cases, if a drug is available from alternative sources, SimpleScripts Rx will make all options available to the covered person. If a drug is not on the formulary, (Non-Formulary with Exceptions) SimpleScripts Rx will provide advocacy to the Covered Person for such medications. Expenses Not CoveredThis benefit will not cover a charge for any of the following:(1) Generic Drugs. Expense incurred for brand name prescription drugs which exceed the cost of the generic brand, when the Generic drug is available, and the name brand is dispensed.(2) Outside the United States. Prescriptions filled outside the United States for non-Emergency medical conditions(3) Refills. Refills greater than the number of times specified by a Physician. Refills after one year from the date of order by a Physician.(4) Administration. Any charge for administering the Prescription Drug.(5) Consumed on premises. Any drug or medicine that is consumed or administered at the place where it is dispensed.(6) Devices. Devices of any type, even though such devices may require a prescription. These include(but are not limited to) therapeutic devices, artificial appliances, braces, support garments, or any similar device.1 of 4(7) Drugs used for cosmetic purposes. Charges for drugs used for cosmetic purposes, such as anabolic steroids, Retin A or medications for hair growth or removal.(8) Experimental. Experimental drugs and medicines, even though a charge is made to the Covered Person.(9) FDA. Any drug not approved by the Food and Drug Administration. Also, any dosage that exceeds the dosage recommended by the United States Food and Drug Administration (FDA) to treat the condition unless outlined in the plan document(10) Growth hormones. Charges for drugs to enhance physical growth or athletic performance or appearance.(11) Immunization. Immunization agents or biological sera.(12) Impotence. A charge for impotence medication.(13) Infertility. A charge for infertility medication.(14) Inpatient medication. A drug or medicine that is to be taken by the Candidate's Name and medicines on its premises.(15) Investigational. A drug or medicine labeled: "Caution - limited by federal law to investigational use".(16) Medical exclusions. A charge excluded under Medical Plan Exclusions.(17) No charge. A charge for Prescription Drugs which may be properly received without charge under local, state or federal programs.(18) Non-legend drugs. A charge for FDA-approved drugs that are prescribed for non-FDA-approved uses.(19) No prescription. A drug or medicine that can legally be bought without a written prescription.(20) Therapeutics. Therapeutic devices or appliances, including hypodermic needles and syringes other than when used for insulin; support garments; other non-medical items, regardless of their intended use.(21) Other. Immunizing agents, biological sera, blood or plasma, and laetrile. 2 of 42020 $0 ACA MEC FORMULARY3of 4Brand Dosage Form Max Retail Brand Dosage Form Max Retail ASPRINAspirin 81 MG Chewable Tablet 30 Tablets Aspirin 81 MG Tablet DR/EC 30 Tablets BOWEL PREPARATIONBISAC/NACL/NaHCo3/KCL/Peg 3350 5 MG-210 G Kit 1 Kit BREAST CANCER PREVENTIONTamoxifen Citrate 10 MG Tablet 30 Tablets Tamoxifen Citrate 20 MG Tablet 30 Tablets CONTRACEPTIVESApri .15/.03 MG Tablet 28 Tablets Norethindrone 0.35 MG Tablet 28 Tablets Desog-E.estradiol/E.estradiol 21-5 Tablet 28 Tablets Norethindrone Ac-Eth Estradiol 1 MG-20 MCG Tablet 28 Tablets Desogestrel-Ethinyl Estradiol 0.15-0.03 Tablet 28 Tablets Norethindrone Ac-Eth Estradiol 1.5-0.03 MG Tablet 28 Tablets Desogestrel-Ethinyl Estradiol 7 Days x3 Tablet 28 Tablets Norethindrone-E.estradiol-Iron 1 MG-20 (21) Tablet 21 Tablets Ethinyl Estradiol/Drospirenone 0.02-3 (24) Tablet 28 Tablets Norethindrone-E.estradiol-Iron 1 MG-20 (24) Tablet 24 Tablets Ethinyl Estradiol/Drospirenone 0.03 MG-3 MG Tablet 28 Tablets Norethindrone-E.estradiol-Iron 1.5-30 (21) Tablet 21 Tablets Ethynodiol D-Ethinyl Estradiol 1 MG-35 MCG Tablet 28 Tablets Norethindrone-E.estradiol-Iron 5-7-9-7 Tablet 28 Tablets Ethynodiol D-Ethinyl Estradiol 1 MG-50 MCG Tablet 28 Tablets Norethindrone-Ethinyl Estrad 0.4-0.035 Tablet 28 Tablets Junel FE 1/20 1 MG-20 MCG Tablet 28 Tablets Norethindrone-Ethinyl Estrad 0.5-0.035 Tablet 28 Tablets Levonorgestrel 1.5 MG Tablet 28 Tablets Norethindrone-Ethinyl Estrad 1 MG-35 MCG Tablet 28 Tablets Levonorgestrel-Ethin Estradiol 0.1-0.02 Tablet 28 Tablets Norethindrone-Ethinyl Estrad 7 Days x3 Tablet 21 Tablets Levonorgestrel-Ethin Estradiol 0.15-0.03 3 Mo. Tablet Dose Pack 1 Pack Norethindrone-Ethinyl Estrad 7-9-5 Tablet 28 Tablets Levonorgestrel-Ethin Estradiol 0.15-0.03 Tablet 28 Tablets Norgestimate-Ethinyl Estradiol .PHONE NUMBER AVAILABLE 7 Days x3 LO Tab 21 Tablets Levonorgestrel-Ethin Estradiol 6-5-10 Tablet 28 Tablets Norgestimate-Ethinyl Estradiol .PHONE NUMBER AVAILABLE 7 Days x3 28 Tab 21 Tablets L-Norgest/E.estradiol-E.estrad 100-20 (84) 3 Mo. Tablet Dose Pack 1 Pack Norgestimate-Ethinyl Estradiol 0.25-0.035 Tablet 28 Tablets L-Norgest/E.estradiol-E.estrad 150-30 (84) 3 Mo. Tablet Dose Pack 1 Pack Norgestimate-Ethinyl Estradiol 7 Days x3 28 Tablet 21 Tablets Medroxyprogesterone Acetate 10 MG Tablet 28 Tablets Norgestimate-Ethinyl Estradiol 7 Days x3 LO Tablet 21 Tablets Medroxyprogesterone Acetate 150 MG/ML Suspension 1 ML Norgestrel-Ethinyl Estradiol 0.3-0.03 MG Tablet 28 Tablets Medroxyprogesterone Acetate 2.5 MG Tablet 28 Tablets Norgestrel-Ethinyl Estradiol 0.5 MG-50 Tablet 28 Tablets Nonoxynol 9 3% Gel 30 Grams Viorele .15/.02/.01 MG Blister Card 1 Pack Noreth-Ethinyl Estradiol/Iron 0.4-35 (21) Chewable Tablet 21 Tablets FLUORIDE SUPPLEMENTSMultivitamins w/Fluoride Drops 0.25 MG/ML Drops 10 ML Sodium Fluoride 0.25 (0.55) Chewable Tablet 15 Tablets Pedi MVI No. 12/Sodium Fluoride 0.25 MG Chewable Tablet 30 Tablets Sodium Fluoride 0.25 MG/ML Drops Pedi MVI No. 12/Sodium Fluoride 0.5 MG Chewable Tablet 30 Tablets Sodium Fluoride 0.4% Gel Pedi MVI No. 16 with Fluoride 0.25 MG Chewable Tablet 30 Tablets Sodium Fluoride 0.5 (1.1) MG Chewable Tablet 30 Tablets Pedi MVI No. 16 with Fluoride 0.5 MG Chewable Tablet 30 Tablets Sodium Fluoride 0.5 MG/ML Drops 50 ML Sodium Fluoride 0.125/Drop Drops Sodium Fluoride 1.1% Gel 56 Grams Sodium Fluoride 0.2% Solution 473 MLFOLIC ACID SUPPLEMENTSFolic Acid 0.8 MG Capsule 30 Capsules Folic Acid 0.8 MG Tablet 30 Tablets STATINSAtorvastatin Calcium 10 MG Tablet 30 Tablets Pravastatin Sodium 80 MG Tablet 30 Tablets Atorvastatin Calcium 20 MG Tablet 30 Tablets Rosuvastatin Calcium 5 MG Tablet 30 Tablets Lovastatin 10 MG Tablet 30 Tablets Rosuvastatin Calcium 10 MG Tablet 30 Tablets Lovastatin 20 MG Tablet 30 Tablets Simvastatin 5 MG Tablet 30 Tablets Lovastatin 40 MG Tablet 30 Tablets Simvastatin 10 MG Tablet 30 Tablets Pravastatin Sodium 10 MG Tablet 30 Tablets Simvastatin 20 MG Tablet 30 Tablets Pravastatin Sodium 20 MG Tablet 30 Tablets Simvastatin 40 MG Tablet 30 Tablets Pravastatin Sodium 40 MG Tablet 30 Tablets4 of 42020 $0 ACA MEC FORMULARYBrand Dosage Form Max Retail Brand Dosage Form Max Retail TOBACCO CESSATIONBupropion 75 MG Tablet 30 Tablets Nicotine 7 MG/24 Hr. Patches 14 Patches Bupropion 100 MG Tablet 30 Tablets Nicotine 14 MG/24 Hr. Patches 21 Patches Bupropion HCL SR 100 MG Tablet 12-Hr. SR 60 Tablets Nicotine 21 MG/24 Hr. Patches 7 Patches Bupropion HCL SR 150 MG Tablet 12-Hr. SR 60 Tablets Nicotine Polacrilex 2 MG Gum 100 Gum Bupropion HCL SR 200 MG Tablet 12-Hr. SR 60 Tablets Nicotine Polacrilex 2 MG Lozenge 72 Lozenge Bupropion XL 150 MG Tablet 24-Hr. ER 30 Tablets Nicotine Polacrilex 4 MG Gum 100 Gum Bupropion XL 300 MG Tablet 24-Hr. ER 30 Tablets Nicotine Polacrilex 4 MG Lozenge 72 Lozenge Bupropion ER 150 MG/12 Hr. Tablets 60 TabletsVITAMIN D SUPPLEMENTSCholecalciferol (Vitamin D3) 400 Unit Tablet 28 Tablets Cholecalciferol (Vitamin D3) 1000 Unit Tablet 30 Tablets Cholecalciferol (Vitamin D3) 400/ML Drops 50 MLPROGRAM DETAILS:1. Your MEC (Minimal Essential Coverage) Medication Program includes all ACA (Affordable Care Act) drugs at no charge.2. You may pick-up your prescription medication at any retail pharmacy of your choice(67,000 in our network).3. Present your ID Card to the pharmacy of your choice to utilize benefits. 4. All medications require a prescription.5. No limit on prescription medication orders.6. You also get access to the entire suite of SimpleScripts Rx products and discounts! HOW THIS PROGRAM WORKS:1. Search for medications by entering drug name in search bar. If a medication is not on the No-cost Medication Program, a price will be displayed. 2. Present your ID Card to the pharmacy of your choice. Your ID Card will display your BIN, Group Number and PCN to present to the pharmacist. You will pay nothing at the pharmacy. 3. If you need other medications, easily search our website for deeply discounted prices. This a Pharmacy Subscription Service. THIS IS NOT INSURANCE. We provide you direct access to medications at negotiated PBM pricing, and Home Delivery Pharmacy pricing on a pre-paid basis. Your Rx Card offers solutions for high-priced specialty medications via an International Pharmacy or PAP service. In addition, a discount pharmacy solution is available, where you search discount options and are directed to a specific pharmacy for super-low pricing. Sometimes, this can be your lowest price option.Your Rx Card is NOT Insurance. Discount Only Discounts are available exclusively through participating pharmacies. The range of the discounts will vary depending on the type of prescription and the pharmacy chosen. This part of the program does not make payments directly to pharmacies. Members are required to pay for all prescription purchases. Cannot be used in conjunction with insurance. You may contact customer care anytime with questions or concerns, to cancel your registration, or to obtain further information. This program is administered by Medical Security Card Company, LLC, Tucson, AZ. Your Rx Card is not available in the following states: MD, WA, ME. Pricing is subject to change without notice. Most pharmacies will accept Your Rx Card, but it is not guaranteed. The final price is determined by your local pharmacy. Formulary and pricing are subject to change. Please see website for current pricing. SSR_2019ED |
