Legalrxbroqsrev11_04.qxd

Satisfaction guarantee
This program is designed save you money on prescrip-
How can I keep my prescription drug costs down?
tion drug costs! We will help you find low-cost medica-
The use of generic prescription drugs, whenever tions within the same therapeutic class as a drug you available, is most cost effective. Don’t be shy – discuss your prescription options with your doctor. Ask This formulary program has the following benefit tiers: whether an alternative, less expensive option would and receive a full refund of the plan cost.
SAVE MONEY ON PRESCRIPTION DRUGS
1st TIER: Generic Drugs
How will I know if a generic equivalent is available?
About the Administrator
Your payment is up to $10
HPA is a fully licensed, full-service Third Party Simply ask your local pharmacist or call the customer Available at over 42,000 pharmacies nationwide service department to find out about generic equiva- Administrator transacting business worldwide.
lents for your prescription. Also ask your doctor to Established in 1939, HPA is a third generation com- 2nd TIER: Brand Name and Select Generic Drugs
prescribe generics whenever possible and appropriate.
pany providing state-of-the-art industry leading Your payment is up to $20
(Your new member packet will include helpful materi- insurance services, including customer service, claims payment, billing and reporting. HPA’s specialty prod- ucts division was founded by Michael Kosloske who 3rd TIER: Brand Name and Select Generic Drugs
What is the difference between brand name and generic drugs?
Your payment is up to $50
The brand name is the trade name under which the Generic Drugs: You pay up to $10 (Tier 1) product is advertised and sold, and is protected by About the Pharmacy Manager
patents so that it can only be produced by one manu- 4th TIER: Brand Name Drugs
Founded in 2002, Advance Benefits develops facturer for a predetermined number of years. Once a innovative benefit designs and programs to meet We have negotiated special discount prices that save
patent expires, other companies may manufacturer a the varying needs of employers and health plans.
you up to 45% off the retail cost.
generic equivalent, providing they follow stringent FDA Advance Benefits is an experienced benefits manage- Generic drugs are drugs for which the patent has ment company that offers a variety of pharmacy To get the most out of this program you should ask
expired, allowing other manufacturers to produce and benefits and leads the way in introducing novel your doctor to prescribe a drug within Tiers 1, 2 or 3 if distribute the product under a generic name. Generics programs for employers and healthcare providers.
possible. Often drugs within the same therapeutic class are essentially a chemical copy of their brand name can be prescribed in place of an expensive brand name equivalents. The color or shape may be different, but drug. Of course if you choose the higher price brand the active ingredients must be the same for both. The name drug, we have negotiated a substantial discount to list contains a wide range of generic and brand name preferred products that have been approved by the PLEASE NOTE: Not all FDA approved Generic, Preferred
or Brand name drugs are included in Tiers 1, 2, 3 or4. A complete list of all drugs included in this plan Contact the pharmacy benefit manager’s Help Desk and Customer Service Department toll free at 866-866-2382
What drugs are considered preferred (formulary) on the plans?
are listed at www.hpa-inc.com. Pricing and Tier Monday through Friday from 9 a.m. to 4 p.m. Eastern A preferred drug list is a list of recommended prescrip- Position are subject to change without notice. Tier tion medications that is created, reviewed and continu- position and pricing is only for quantities stated, ally updated by a team of physicians and pharmacists.
additional quantities may result in higher costs. This The preferred drug list contains a wide range of generic and brand name preferred products that have been approved by the FDA. Your doctor can use this list to When can I begin saving on my prescriptions?
select medications for your health care needs, while The effective date is the day after HPA’s administrative helping you maximize your prescription drug benefit. A office receives your application and your first month’s medication becomes a preferred drug based on safety payment. Your identification card will be mailed to you.
and efficacy, then on cost-effectiveness.
Administered by: Health Plan Administrators, Inc., Rockford, IL The Member Enrollment Kit will be sent to you via email. A complete drug list is available at What is the difference between a preferred brand name drug
versus a non-preferred brand name drug?
This brochure provides a brief description of The Competitor A preferred brand name drug is a medication that has Rx-Pay Card. Plan may not include all drugs. The drug list is What is a generic drug?
been reviewed and approved by a group of physicians subject to change with additions or deletions without notice.
Once a patent on a brand name drug expires, other and pharmacists, and has been selected for preferred The Pharmacy Benefit Manager is Advance Benefits. This plan
drug companies may make a generic version of the status based on its proven clinical and cost effectiveness. is not an insurance plan.
drug, with the approval of the Food and Drug A non-preferred brand name drug is a medication Administration (FDA). The FDA’s standards for quality that has been reviewed by the same team of physicians 2004 HPA, Inc. All rights reserved.
are the same for all manufacturers. This means the and pharmacists who determined that a clinically generic drug contains the same active ingredients as the equivalent alternative drug that is most cost effective is brand name whose patent has expired, and that it is available. These designations may change as new clini- The Competitor Rx-Pay Card Enrollment Form for HPA, Inc.
What drugs are considered preferred (formulary) on
A complete Prescription Drug List is available on C. SELECT YOUR PAYMENT OPTIONS
Discount Plans?
A. TELL US ABOUT YOURSELF
The Competitor Rx product guide contains certain brand drugs for which the member’s price is the sched- Total Due (from calculation section on opposite page) $
uled amount listed. Drugs that are chemically or thera- Select your payment plan:
peutically similar to drugs listed on the product guide Up to $10 payment
Up to $20 payment
are not discounted. Prices are subject to change due to IMPORTANT: If you choose to pay monthly, you must pay by electronic bank draft or credit card only.
manufacturer price changes to pharmacies. On these drugs, the participant enjoys two distinct dis- Select your payment method:
counts, one through the Competitor Rx pharmacy net- Check or money order. Enclose initial payment to HPA, Inc., with the application.
work and the second through the manufacturer.
What if the brand drug I am taking is not discounted?
I authorize Health Plan Administrators, Inc., to charge the above credit card for the premium If you are currently taking a medication that has simi- listed according to the payment mode selected.
lar active ingredients or is used to treat the same con- ditions as the preferred brand drugs on the Competitor Rx Pay Card product guide, it will still be discounted.
*You must list an email address since your Rx Pay fulfillment kit and i.d. card are Automatic bank withdrawal. Enclose initial payment and a voided check with You will pay the Competitor Rx negotiated price for that drug. To take advantage of the potential program Your Rx Pay monthly fee will automatically be withdrawn from your savings on listed preferred drugs, you should ask your Complete if spouse and/or children are included:
pharmacist (where regulations permit) or a doctor to change your medication, where medically appropriate, to a less expensive product listed in the product guide.
pay and charge my account debits drawn from my account by Health Plan Administrators, Inc., to its order. This authorization will stay in effect until I revoke it in writing. Until you Is the Rx-Pay Card available for child only use?
receive such notice, I agree that you shall be fully protected in honoring any such debits. I Yes, if the Rx-Pay Card is for a child only (no adults also agree that you may at any time, end this agreement by giving 30 days advanced writ- will be using the card), list the child’s name and infor- Up to $50 payment
ten notice to me and to Health Plan Administrators, Inc. You are to treat such debit as if it mation as the applicant and the parent and legal were signed by me. If you dishonor such debit with or without cause, I will not hold you guardian must sign the enrollment form. The monthly B. CHOOSE YOUR DESIRED COVERAGE
liable even if it results in loss of my Rx Pay membership.
cost is $19.99 (same as a member). If there is more than one child to be covered, list the oldest as the applicant and the others under Children Included. The Augmentin Sus 125-250 mg Premarin 0.3-1.25 monthly cost is $28.99 (same as a member + children).
D. SIGN THE ENROLLMENT FORM
SOLICITOR USE ONLY: Attach the HPA Statement of Understanding Form
I hereby apply for membership enrollment in HPA, Inc. prescription program. I understand that Pharmacy Network
acceptance of this enrollment for membership is guaranteed. I understand that the earliest my The Competitor Rx-Pay Card is accepted at over enrollment can become effective is the day after HPA’s receipt of the completed enrollment form 42,000 pharmacies throughout the United States. The HPA # 640000000
and the first month’s payment. I also understand that by participating in this program external network includes pharmacy chains, such as, CVS, Rite factors may force a change in monthly fee, benefits and/or preferred drug list at any time. I Aid, Medicine Shoppe, Walgreens, Wal-Mart, and will be entitled to negotiated and funded discounts on eligible prescription drugs purchased from more, as well as thousands of independent pharmacies Up to 45% discounts
any participating pharmacy. As a member of HPA, Inc. membership program we understand thatyour trust in us is one of our most important assets. In order to preserve that trust, we want This tier offers special discount pricing on drugs not found in you to understand our information practices and your rights to ask us not to share certain infor- mation about you. As a member of this plan we want you to know the following: "THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY." Rx Options, Inc.
will without your consent or authorization submit online pharmacy claim data to manufacturers, Eligible Member and/or Spouse through age 64 years old: 1. Select your plan monthly cost from the chart with NO member identification, for the payment of the rebates. Online Claims data will also be Member: $19.99
Member+Child(ren): $28.99
provided to employers and pharmacies regarding invoicing and payments in the standard NCPDP Mail your enrollment form and initial payment to: 2. If you are prepaying more than 1 month, multiply the claims billing format. If you have signed up for the email online reminders regarding refills of Member+Spouse: $28.99
Family: $34.99
HPA, Inc., P.O. Box 15250, Rockford, IL 61132-5250.
your current medications, emails will be sent to you directly at the email address you list on number of months by the monthly rate (quarterly = x3; your enrollment application. If you wish to revoke the right for us to use your personal health *Eligible Member and/or Spouse ages 65 years and older: information (PHI), you must do so in writing to HPA, Inc., 3703 N. Main Street, Rockford, IL, Member: $21.99
Member+Child(ren): $30.99
61103-1679. Your request will be processed within 60 days upon receipt. Revoking the right for us to use your personal health information may also terminate your benefit.
Save time and postage by paying with a credit card and faxing Member+Spouse: $30.99 Family: $36.99
toll free the completed, signed & dated application and rate and Applicant’s Signature
* If either the member or spouse is age 65 years or older, you must pay the age 65+ monthly cost. calculation chart to: 1-888-FAX-HPA1 (329-4721)
Signature authorizes release of information and enrollment into the program. The enrollment kit is sent via email. We do not have preprinted materials.

Source: http://www.americanretiredpersons.com/InsuranceServices/hpa/Rx-PayCard.pdf