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Benefits & Services Prescription Benefits

TML Health, Pharmacy Benefit Manager, Attending Physician, TML Health Medical Management Team, community Pharmacist, and the covered individual will work together to provide a progressive Medication Therapy Management Program for political subdivisions. TML Health’s Medication Therapy Management Program will enhance the covered individual’s ability as an educated consumer regarding evidence based prescription utilization. TML Health works closely with evidence based medicine subject matter experts to ensure the Medication Therapy Management Program is clinically supported by pharmaceutical alternatives based on the covered individual’s choice.

Coverage for prescriptions and biotech/biosimilar prescriptions that are available through the Pharmacy Benefit Manager will be paid per the prescription Summary of Benefits and Coverage. Eligible biotech/biosimilar prescriptions may be purchased from network providers per the prescription Summary of Benefits and Coverage. For eligible prescriptions purchased outside of the Pharmacy Benefit Manager or the network providers, the plan will pay at the out of network benefit percentage and will not, at any time, pay at 100% for any prescription services under the out of pocket provision of the Plan. The plan includes several copay options to allow the educated consumer to manage their out of pocket expense.

Pharmacy Benefit Manager Administrative Services:

TML Health Preferred Formulary

For additional Forms and Publications, please log into TML Health

TML Health Preferred Formulary - OptumRx
Specialty Vaccination Network

  • Effective Cost Management Pricing
    • Effective Cost Management Pricing
    • Maximum Allowable Cost (MAC)
    • Average Wholesale Pricing (AWP)
    • Average Sales Pricing (ASP)
      • Generic Fixed Fee Schedule Pricing analyzed quarterly with pricing update as appropriate
      • Reference Pricing
        Involves designs where plans pay a fixed price for a particular procedure which certain providers will accept as payment in full. The goal is to negotiate cost effective arrangements with high quality providers. Plans may have a reference based pricing program where they do not count amounts above the reference price paid by participants toward the out-of-pocket limit. Plans would treat providers who accept the reference amount as the plans’ only in network providers and would have to use a reasonable method to ensure that it provides adequate access to high quality providers.
  • MAC A Plan
    • If a brand name drug is dispensed and a generic alternate drug exists, the covered individual pays the difference between the brand name and generic price in addition to the appropriate copayment for the brand name. The cost difference between the brand name and generic price does not apply to any individual deductibles or out of pocket amounts. The MAC differential applies to all prescriptions purchased through this program when a generic alternate is available.
  • MAC C Plan
    • Covered individual will pay the appropriate copayment amount of the prescription.
  • Prior Authorization, Step Therapy, and Cost Share Evidence Based Management Services are provided.
  • Tiered Copay Options to enhance the management of the covered individuals out of pocket expenses.
    • Over the Counter
    • Retail Network Options - Align and/or Broad
    • Generic - Retail and Mail
    • Best Brand Price Drug List (Formulary) - Retail and Mail
    • Non Best Brand Price List (Non-Formulary) - Retail and Mail
    • Cost Share Copay: Retail and Mail
    • Biotech/Biosimilar - Mail 34 day dispensement

For more information about how TML Health can help you manage your benefit costs, please Contact Us today!