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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
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
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
A. TELL US ABOUT YOURSELF
The Competitor Rx product guide contains certain
brand drugs for which the member’s price is the sched-
(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
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
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
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,
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
toll free the completed, signed & dated application and rate and
* 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.
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