Hpa0704252438_rxcardw/o#

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 whether an alternative, less expensive option would and receive a full refund of the plan cost.
SAVE MONEY ON PRESCRIPTION DRUGS
THE FIRST TIER: Generic Drugs
About the Administrator
You pay up to $10
How will I know if a generic equivalent is available?
HPA is a fully licensed, full-service Third Party ■ Available at over 42,000 pharmacies nationwide Simply ask your local pharmacist or call the customer Administrator transacting business worldwide.
service department to find out about generic equiva- Established in 1939, HPA is a third generation com- ■ Automatic acceptance — no health questions SECOND TIER: Brand Name and Select Generic Drugs
lents for your prescription. Also ask your doctor to pany providing state-of-the-art industry leading You pay up to $20
prescribe generics whenever possible and appropriate.
insurance services, including customer service, claims (Your new member packet will include helpful materi- payment, billing and reporting. HPA’s specialty prod- Preferred Brand & Select Generic: up to $20 ucts division was founded by Michael Kosloske who THIRD TIER: Brand Name Drugs - You pay up to $50
* We have negotiated special discount prices. Savings range as high What is the difference between brand name and generic drugs?
■ No pre-existing conditions limitation The brand name is the trade name under which the About the Pharmacy Manager
product is advertised and sold, and is protected by Founded in 2002, Advance Benefits develops ■ No deductible and no monthly or annual maximums patents so that it can only be produced by one manu- innovative benefit designs and programs to meet To get the most out of this program you should ask
facturer for a predetermined number of years. Once a the varying needs of employers and health plans.
your doctor to prescribe a drug within the first two patent expires, other companies may manufacturer a Advance Benefits is an experienced benefits manage- tiers, if possible. Often drugs within the same therapeu- generic equivalent, providing they follow stringent FDA ment company that offers a variety of pharmacy tic class can be prescribed in place of an expensive benefits and leads the way in introducing novel brand name drug. Of course if you choose the higher Generic drugs are drugs for which the patent has programs for employers and healthcare providers.
price brand name drug, we have negotiated a substantial expired, allowing other manufacturers to produce and distribute the product under a generic name. Generics Contact the pharmacy benefit manager’s Help Desk are essentially a chemical copy of their brand name and Customer Service Department toll free at equivalents. The color or shape may be different, but PLEASE NOTE: Not all FDA approved Generic, Preferred
866-866-2382 Monday through Friday from 9 a.m.
the active ingredients must be the same for both. Thelist contains a wide range of generic and brand name or Brand name drugs are included in Tiers 1, 2 or 3.
preferred products that have been approved by the a complete list of all drugs included in this plan are listed at www.hpa-inc.com. Pricing and Tier Position are subject to change without notice. Tier positionand pricing is only for quantities stated, additional What is a preferred drug list?
quantities may result in higher costs. This is not an When can I begin saving on my prescriptions?
A preferred drug list is a list of recommended prescrip- The effective date is the day after HPA’s administrative tion medications that is created, reviewed and continu- office receives your application and your first month’s ally updated by a team of physicians and pharmacists.
payment. Your identification card will be mailed to you.
The preferred drug list contains a wide range of generic The Member Enrollment Kit will be sent to you via and brand name preferred products that have beenapproved by the FDA. Your doctor can use this list to email. A complete drug list is available at select medications for your health care needs, while Administered by: Health Plan Administrators, Inc., Rockford, IL helping you maximize your prescription drug benefit. A What is a generic drug?
medication becomes a preferred drug based on safety and efficacy, then on cost-effectiveness.
This brochure provides a brief description of The Competitor Once a patent on a brand name drug expires, other Rx Co-Pay card. Plan may not include all drugs. The drug list drug companies may make a generic version of the is subject to change with additions or deletions without notice.
drug, with the approval of the Food and Drug What is the difference between a preferred brand name drug
The Pharmacy Benefit Manager is Advance Benefits. This plan
Administration (FDA). The FDA’s standards for quality versus a non-preferred brand name drug?
is not an insurance plan.
are the same for all manufacturers. This means the A preferred brand name drug is a medication that has generic drug contains the same active ingredients as the been reviewed and approved by a group of physicians 2004 HPA, Inc. All rights reserved.
brand name whose patent has expired, and that it is and pharmacists, and has been selected for preferred status based on its proven clinical and cost effectiveness. A non-preferred brand name drug is a medication The Competitor Rx Co-Pay Enrollment Form for HPA, Inc.
that has been reviewed by the same team of physiciansand pharmacists who determined that a clinically A complete Preferred Drug List is available on the A. TELL US ABOUT YOURSELF
C. SELECT YOUR PAYMENT OPTIONS
equivalent alternative drug that is most cost effective isavailable. These designations may change as new clini- HPA website at www.hpa-inc.com and also is Total Due (from calculation section on opposite page) $
included in your new member enrollment packet along with your identification card.
Select your payment plan:
What drugs are considered preferred (formulary) on
Discount Plans?
IMPORTANT: If you choose to pay monthly, you must pay by electronic bank draft or credit card only.
$10 Generic
$20 Brand Name and
The Competitor Rx product guide contains certain Select your payment method:
brand drugs for which the member’s price is the sched- Select Generic
❏ Check or money order. Enclose initial payment to HPA, Inc., with the application.
uled amount listed. Drugs that are chemically or thera- peutically similar to drugs listed on the product guide are not discounted. Prices are subject to change due to manufacturer price changes to pharmacies. I authorize Health Plan Administrators, Inc., to charge the above credit card for the premium On these drugs, the participant enjoys two distinct dis- listed according to the payment mode selected.
counts, one through the Competitor Rx pharmacy net- work and the second through the manufacturer.
*You must list an email address since your Rx Co-Pay fulfillment kit and i.d. card are ❏ Automatic bank withdrawal. Enclose initial payment and a voided check with What if the brand drug I am taking is not discounted?
Your Rx Co-pay monthly fee will automatically be withdrawn from your Complete if spouse and/or children are included:
If you are currently taking a medication that has simi- lar active ingredients or is used to treat the same con- ditions as the preferred brand drugs on the Competitor Rx Co-Pay product guide, it will still be discounted.
pay and charge my account debits drawn from my account by Health Plan Administrators, You will pay the Competitor Rx negotiated price for Inc., to its order. This authorization will stay in effect until I revoke it in writing. Until you that drug. To take advantage of the potential program receive such notice, I agree that you shall be fully protected in honoring any such debits. I savings on listed preferred drugs, you should ask your also agree that you may at any time, end this agreement by giving 30 days advanced writ- pharmacist (where regulations permit) or a doctor to ten notice to me and to Health Plan Administrators, Inc. You are to treat such debit as if it change your medication, where medically appropriate, were signed by me. If you dishonor such debit with or without cause, I will not hold you B. CHOOSE YOUR DESIRED COVERAGE
to a less expensive product listed in the product guide.
liable even if it results in loss of my Rx Co-pay membership.
Discount Pricing for
D. SIGN THE ENROLLMENT FORM
The Competitor Rx Co-Pay card is accepted at Brand Name Non-Preferred Drugs
SOLICITOR USE ONLY: Attach the HPA Statement of Understanding Form
I hereby apply for membership enrollment in HPA, Inc. prescription program. I understand that over 42,000 pharmacies throughout the United acceptance of this enrollment for membership is guaranteed. I understand that the earliest my States. The network includes pharmacy chains, enrollment can become effective is the day after HPA’s receipt of the completed enrollment form and the first month’s payment. I also understand that by participating in this program external factors may force a change in monthly fee, benefits and/or preferred drug list at any time. I Walgreens, Wal-Mart, and more, as well as will be entitled to negotiated and funded discounts on eligible prescription drugs purchased from thousands of independent pharmacies throughout any participating pharmacy. As a member of HPA, Inc. membership program we understand that your trust in us is one of our most important assets. In order to preserve that trust, we want 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 *$50.00 for brand name & select generic drugs listed in Tier 3. For the drugs DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW not listed in Tier 1, 2 or 3, members pay the network negotiated price 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 Single and/or Spouse ages 18 through 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 Single: $19.99
Single+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: HPA, Inc., P.O. Box 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 Single+Spouse: $28.99
Family: $34.99
15250, Rockford, IL 61132-5250. Make personal check or money 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 Single and/or Spouse ages 65 years and older: order payable to: Health Plan Administrators, Inc.
information (PHI), you must do so in writing to HPA, Inc., 3703 N. Main Street, Rockford, IL, Single: $21.99
Single+Child(ren): $30.99
61103-1679. Your request will be processed within 60 days upon receipt. Revoking the right Save time and postage by paying with a credit card and faxing for us to use your personal health information may also terminate your benefit.
Single+Spouse: $30.99
Family: $36.99
toll free the completed, signed & dated application and rate and calculation chart to: 1-888-FAX-HPA1 (329-4721)
Applicant’s Signature
* If either the single or spouse is age 65 years or older, you must pay the age 65+ monthly cost. 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.brodskyagency.com/Downloads/HPA/RxCo-pay%20brochure7-1-04.pdf