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
Dombo e-Journal E-ditorial board: E-Copy to: dombo@xray.bmc.uu.se E-Phone: busy E-Fax: out of paper E - U R L : http: / / x r a y . b m c . u u . s e / d o m b o _______________________________________ _______________________________________ Overheard Dombo Top 3 • Remco: You measure the sexual excitement of men with The Top 3 of Nothing In Particular:a ruler and of
Opening Remark Symposium 1 Chairpersons: Ryo Sumazaki University of Tsukuba Tetsuo Hori University of Tsukuba Keynote Lecture 1 University of Tsukuba Ryo Sumazaki Keynote Lecture 2 Teikyo-Heisei-University Sadao Yasugi Special Lecture 1 Chairperson: Hiromichi Ikawa Kanazawa Medical University Molecular motors: Kinesin superfamily proteins as key mo
ATLANTIC MEDICAL IMAGING
ATLANTIC MEDICAL IMAGING