Citi Benefits Handbook
Medical Specialty Drugs Administered by a Medical Provider
Aetna and Anthem will provide the following medical specialty medication programs to plan members:
Mandatory Site of Care Redirection Program
If you receive certain specialty drugs at an outpatient hospital facility, you may receive a letter from Aetna or Anthem about utilizing a lower level of care which meets your needs. This would include receiving your infusion in the office setting, an infusion center, or in the comfort of your home through a home infusion provider. If this affects you, Aetna or Anthem will work with you to transition your care to one of these settings, or call your Citi Health Concierge at the number on your medical ID card to learn more.
Precertification is required for certain Medically Administered Specialty Drugs to help make sure proper use and guidelines for these drugs are followed. Your provider will submit clinical information which will be reviewed for decision. Aetna or Anthem will give the results of the decision to both you and your provider by letter.
For a list of Medically Administered Specialty Drugs that need precertification, please contact Aetna or Anthem at the number on your medical ID card. The precertification list is reviewed and updated from time to time. Including a Specialty Drug on the list does not guarantee coverage under your Plan. Your provider may check with Aetna or Anthem to verify Specialty Drug coverage, to find out which drugs are covered and if precertification is required.
If you are receiving an infused medication, certain medications may require use of the lowest cost site of care.
Site of Care Programs
Aetna's Site of Care program and Anthem's Right Drug Right Channel program target self-administered specialty drugs that can be best managed through the pharmacy benefit program rather than through the medical plan. If you are currently receiving a specialty drug which is on the drug list for this program through your medical benefit, you will need to get the drug through your pharmacy benefit.
If the drug you take is given as an injection, you will need to give the drug(s) to yourself and it will now be provided through your pharmacy benefit program. Your doctor or nurse can teach you or a caregiver how to give the injection. You can also ask your doctor to call the Provider Services number on your medical ID card and find out if a nurse can train you at home.
If you are enrolled in the Aetna Choice Plan or Aetna In-Network Only medical plan option and taking an eligible medication, the PrudentMed Solution will help you to enroll in a manufacturer copay assistance program. Medications on the PrudentMed Program Drug List are included in the program and will be subject to a 30% coinsurance. However, if you are participating in the PrudentMed Solution, which includes enrollment in an available manufacturer copay assistance program for their specialty medication, you will have a $0 out-of-pocket responsibility for your prescriptions covered under the PrudentMed Solution.
Copay assistance is a process in which drug manufacturers provide financial support to patients by covering all or most of the patient cost share for select medications – in particular, specialty medications. The PrudentMed Solution will assist you in obtaining copay assistance from drug manufacturers to reduce your cost share for eligible medications thereby reducing out-of-pocket expenses. Participation in the program requires certain data to be shared with the administrators of these copay assistance programs, but please be assured that this is done in compliance with the Health Insurance Portability and Accountability Act (HIPAA).
If you currently take one or more specialty medications included in the PrudentMed Program Drug List, you will receive a welcome letter from PrudentRx that provides information about the PrudentMed Solution as it pertains to your medication. All eligible members must call PrudentRx at 1 (855) 476-4118 to register for any manufacturer copay assistance program available for your specialty medication as some manufacturers require you to sign up to take advantage of the copay assistance that they provide for their medications. If you do not call to register, PrudentRx will make outreach to you to assist with questions and enrollment. If you choose to opt out of the PrudentMed Solution, you must call 1 (855) 476-4118. Eligible members who fail to enroll in an available manufacturer copay assistance program or who opt out of the PrudentMed Solution will be responsible for paying a 30% coinsurance on specialty medications that are eligible for the PrudentMed Solution.
If you or a covered family member will start a new medication covered under the PrudentMed Solution, you can reach out to PrudentRx or they will proactively contact you so that you can take full advantage of the PrudentMed Solution. PrudentRx can be reached at 1 (855) 476-4118 to address any questions regarding the PrudentMed Solution.
The PrudentMed Program Drug List may be updated periodically.
Payments made on your behalf, including amounts paid by a manufacturer's copay assistance program, for medications covered under the PrudentMed Solution will not count toward your plan deductible or out-of-pocket maximum (if any), unless otherwise required by law. Also, payments made by you for a medication that does not qualify as an "essential health benefit" under the Affordable Care Act (ACA), will not count toward your deductible or your ACA out-of-pocket maximum (if any), unless otherwise required by law. A list of specialty medications that are not considered to be "essential health benefits" is available. An exception process is available for determining whether a medication that is not an essential health benefit is medically necessary for a particular individual.
If you have questions, PrudentRx can be reached at 1 (855) 476-41188.