The Health Plan's nationwide prescription drug benefits are administered by Express Scripts. All participants eligible for the program will be issued an Express Scripts ID card. For participants who are not entitled to the Express Scripts program, prescription drug coverage is provided at the non-network level under the medical benefits.
You and your enrolled dependents are covered under the Express Scripts prescription drug program if this Plan is your primary plan or if your primary plan does not include prescription drug coverage. If Medicare is your primary plan and this Plan is your secondary plan, you and your eligible dependents are covered under the Express Scripts prescription drug program, provided you and your spouse or same-sex domestic partner do not enroll in a Medicare Part D Prescription Drug Program. If you enroll in Medicare Part D, you will not be eligible for any prescription drug coverage under the Plan.
If this Plan is not your primary plan or if you owe the Plan money due to audit findings by the Contribution Compliance or Participant Eligibility Departments, your prescription drug benefits will be covered at the non-network level under the medical benefits. Some key provisions of the prescription drug benefits are outlined below.
|Retail Pharmacy Program||Home Delivery Pharmacy
|Calendar Year Deductible||$150 per person/$300 per family|
|Supply of Medication||Up to a 30-day supply per prescription and/or refill||Up to a 90-day supply per prescription and/or refill|
You will pay the greater of the two copays shown:
In addition, if you receive a brand name drug when a generic exists, you will pay the difference in cost between the generic and brand name medication.
You will pay the greater of the two copays shown:
In addition, if you receive a brand name drug when a generic exists, you will pay the difference in cost between the generic and brand name medication subject to the maximum copays listed above.
|Preventive Services Prescriptions||Generic prescription medications that appear on the list of Affordable Care Act preventive services are not subject to the deductible or copay. See pages 49 and 50.|
|Plan II||Same as Plan I except that prescriptions used for mental health and substance abuse treatment are not covered. See page 60.|
The calendar year deductible for the Express Scripts prescription drug benefit is outlined on the prior page. The deductible applies to both the retail pharmacy program and the home delivery program. The family deductible is satisfied when at least two or more family members have paid $300 in covered expenses, except that the Plan will not apply more than the individual deductible to any one family member. The pharmacist will collect deductible amounts.
Any price differences you are requested to pay between brand and generic drugs do not apply toward the deductible amount.
Your pharmacy copays are outlined on the prior page and vary depending on whether the prescription is a generic, preferred brand or non-preferred brand drug. If your prescription is for a preferred or non-preferred brand name drug that has a generic alternative, you will be responsible for the regular copay plus the difference in price between the generic and brand name prescription. You will be responsible for the brand/generic difference even if your doctor indicates "DAW" (dispense as written) or "no substitution" on the prescription. The price differential does not apply toward the deductible amount.
The Plan uses a formulary or a list of commonly prescribed brand name and generic medications. These medications are selected because they can safely and effectively treat most medical conditions while helping to contain costs. The list of preferred medications is available online at www.express-scripts.com.
You should use a participating retail pharmacy for
short-term prescriptions such as antibiotics to treat
infections. Show your prescription drug ID card to the
pharmacist and pay your retail copay each time you
order a new prescription. Because your card does not
contain your ID number, please remember to share it
as appropriate with your pharmacist when you obtain
To find a participating retail pharmacy near you:
If you use a non-participating pharmacy, you must pay the entire cost of the prescription and then submit a claim form to Express Scripts as described on page 85. You will be reimbursed the amount that would have been charged by a participating retail pharmacy less the required copay. The discounted cost will be used to satisfy your prescription drug deductible.
If you are eligible for an Express Scripts drug card, your prescriptions will not be considered under the medical benefits of the Plan except for certain over-the-counter prescriptions under the list of Affordable Care Act preventive services. Please refer to page 60.
The first time you are prescribed a medication, ask your doctor for two prescriptions: the first for up to a 30-day supply to be filled at a retail pharmacy; the second for the balance, up to a 90-day supply, to be filled through the home delivery pharmacy.
Delivery of Your Medication
Prescription orders are processed promptly and are usually delivered to you within eight days. If you are currently taking a medication, be sure to have at least a 14-day supply on hand when ordering. If you do not have enough, ask your doctor to give you a second prescription for a 14-day supply and fill it at a participating retail pharmacy while your home delivery prescription is being processed.
Paying for Your Medication
You may pay by check, money order, VISA, Master- Card, Discover/NOVUS, American Express or Diners Club.
Please note: The pharmacist's judgment and dispensing restrictions, such as quantities allowable, govern certain controlled substances and other prescribed drugs. Federal law prohibits the return of dispensed controlled substances.
Specialty medications are drugs that are used to treat complex conditions, such as cancer, growth hormone deficiency, hemophilia, hepatitis C, immune deficiency, multiple sclerosis and rheumatoid arthritis. After the initial prescription, these medications must be obtained through Accredo, Express Scripts' dedicated specialty pharmacy, rather than at your local retail pharmacy or through your doctor's office. If you choose to use a pharmacy other than Accredo after the first fill, you will have to pay the entire cost of the prescription.
Accredo includes access to nurses who are trained in specialty medications, pharmacist availability 24/7 and coordination of home care and other health care services. They can also arrange for prescriptions to be delivered to a doctor's office for administration. For more information please call Member Services at (800) 903-4728.
Personalized Medicine Program
Personalized medicine takes advantage of advances in science to help your doctor make more precise and effective prescribing decisions through genetic tests.
These tests, called pharmacogenomics tests, have several advantages, including better outcomes, more precise therapy, dosing decisions and less waste.
If you are using a medication covered by the Personalized Medicine Program, such as warfarin for a heart condition, a pharmacist will contact your doctor to see if it is appropriate for you to participate in the program. If your doctor agrees, you will be contacted by a pharmacist to let you know that the testing is available. If you agree to participate, you will receive a cheek swab test that you can administer on your own. The results will be sent to your doctor and to a specially trained Express Scripts pharmacist who can help your doctor interpret the results. Of course, your doctor decides which drug and dose is right for you.
The Personalized Medicine Program is available to you at no additional cost and requires no action on your part. It is completely voluntary and any decisions to change treatments or dosages remain up to you and your physician. All information gathered during testing is treated confidentially and no tests are conducted other than the tests which you specifically authorize. All aspects of the program comply with privacy regulations under the Health Insurance Portability and Accountability Act (HIPAA) and the Genetic Information Non-Discrimination Act of 2008 (GINA) as well as applicable state laws.
Most of your prescriptions can be filled without prior authorization at a retail pharmacy. However, some drugs are only covered for certain uses or in certain quantities. Lamisil and Wellbutrin SR are examples of medications that require prior authorization by Express Scripts before they can be covered. If you present a prescription requiring prior authorization, your doctor may need to provide additional information before the prescription is covered.
When you take a prescription that needs prior authorization
to the retail pharmacy, the system will
automatically review your file (age, sex and prior
drug therapy history) to determine if the medication
can be dispensed on the criteria available. The
pharmacy will advise you if additional information
is required. Either you or the pharmacy can ask your
doctor to call Express Scripts at (800) 753-2851 to
initiate the prior authorization process. This call will
start a review that typically takes two to five business
days unless additional information is required, in
which case, the review may take longer. Both you and your doctor will be notified in writing of the decision. If the prescription is approved, the letter will tell you the length of your coverage approval. If the prescription is denied, the letter will include the reason for coverage denial and instructions on how to submit an appeal if you choose.
If you want the prescription immediately without waiting for the prior authorization, you will have to pay the full retail price at the pharmacy. If the prescription is approved, your claim should be sent to Express Scripts for reimbursement at 100% minus the prescription drug copay and deductible.
A compound medication is custom-made by a pharmacy based on a doctor's prescription, often including more than one ingredient. At a participating retail pharmacy, you will pay your retail copay for compound medications if the pharmacist submits a claim electronically. In other cases, you must submit a claim for reimbursement to Express Scripts, which must be accompanied by an itemized list of the ingredients with their full 11-digit National Drug Code (NDC) number(s) for the claim to be processed.
Please note: Coverage limits apply to compound medications. The Health Plan will only reimburse the cost of the active main ingredient, minus the copay. In addition, if one ingredient is a non-covered item, the compound claim will be denied.
Male Erectile Dysfunction Drugs
Prescriptions for male erectile dysfunction drugs, including but not limited to, Cialis, Levitra and Viagra, are covered only when there is an underlying medical condition, such as diabetes or prior prostate surgery, that warrants treatment with these medications. Prescriptions are limited to six pills of any combination of these drugs in a 30-day period. These medications require pre-authorization from the Plan and you may contact the Plan Office for a list of the information needed to complete this process.
Alternatively, you may fill your first prescription at a participating pharmacy with your Express Scripts prescription drug card and pay 100% of the discounted price for the prescription. Send your original pharmacy receipt to the Plan Office, along with a letter from your doctor confirming your underlying medical condition warranting treatment, and your medical records for review. If the prescription is determined to be medically necessary, the Plan will forward the claim to Express Scripts for reimbursement at 100% minus the prescription drug copay, subject to the prescription drug deductible.
If you use a non-participating pharmacy, your first claim should be filed with the Plan Office as outlined above. If the prescription is determined to be medically necessary, you will be reimbursed the amount that would have been paid if you had used a participating pharmacy. You are responsible for the remainder of the bill.
After medical necessity is determined, subsequent prescriptions may be filled in the usual way by paying the prescription drug copay at participating pharmacies. For non-participating pharmacies, claims should be submitted to Express Scripts as described on page 85.
Infertility Drugs Prescribed for Non-Infertility Conditions
Certain medications commonly used to treat infertility, may also be prescribed for conditions that are not related to infertility. In these cases, you should follow the procedures for pre-authorization and filing a claim as outlined under "Male Erectile Dysfunction Drugs".
Prescriptions for sleep-aid therapy, such as Ambien or Lunesta, are limited to quantities sufficient to treat 21 days per month. If you require medication in excess of this amount you must obtain a pre-authorization from the Plan. Contact the Plan Office for a list of the information needed to complete the pre-authorization.
Growth hormones are considered specialty medications
and are covered only when purchased through
Accredo. They also require pre-authorization from
the Plan before filling your first prescription. Contact
the Plan Office for a list of the information needed to
complete the pre-authorization. Growth hormones
are not covered for familial short stature, constitutional
growth delay or for non-FDA-approved uses such as anti-aging programs or athletic enhancement.
Ask your doctor to prescribe generic drugs whenever possible. This will help us provide the highest quality medications and program benefits while keeping costs down. We will remind your doctor when a generic equivalent is available for brand name drugs.
Plan II excludes prescription drug coverage for mental health and substance abuse treatment. Based on guidelines established by the National Institute of Mental Health, there are five psychotherapeutic medication categories for which the Plan excludes coverage:
Although Plan II does not pay for these drugs, you are still eligible to receive the Plan's discounted rates from participating retail pharmacies. Simply fill your prescription using your Express Scripts prescription drug card.
The Plan recognizes that some drugs in an excluded category can be used for non-mental health purposes. For example, antipsychotic drugs such as chlorpromazine, haloperidol, and pimozide are used to treat Tourette's syndrome. Certain medications in the mood stabilizer category are anti-seizure drugs used in the treatment of epilepsy, while some anxiolytics are used to treat cardiovascular conditions. The Plan will consider medications that fall under an excluded category only if it is medically established that its use is primarily for non-mental health purposes. All drugs in the excluded categories will require pre-authorization from the Health Plan.
If you need an excluded medication for a non-mental health or substance abuse reason, you should follow the procedures for pre-authorization and filing a claim as outlined on page 59 under "Male Erectile Dysfunction Drugs".
Prescription drug coverage is provided through the medical benefits under the following circumstances:
Prescriptions for over-the-counter medications on the list of preventive services are not subject to the medical deductible or coinsurance and will be paid at 100% of the Plan's Allowance. Other prescriptions and supplies that are processed under the medical benefits will be paid at the non-network level of benefits, subject to the non-network medical deductible and coinsurance.
To receive reimbursement, submit a copy of the drug bill to the Plan Office. If you have primary prescription drug coverage under another plan, you must also submit that plan's Explanation of Benefits (EOB) form. The drug bill must include the prescription number, name of the patient, name of the doctor, quantity filled and strength of medication. Credit card vouchers, cash receipts or canceled checks will not be accepted as bills for processing drug claims. The Plan reserves the right to request original drug receipts should it become necessary to do so.
If you owe the Plan money due to any audit findings
by the Contribution Compliance or Participant
Eligibility Departments, you or your dependents are
not eligible to use the Express Scripts retail or home
delivery programs until the balance due is paid in
full. You will need to submit prescription charges as
outlined previously under "Prescription Drug Coverage
through Your Medical Benefits". As soon as the
Plan has recovered the entire amount that you owe,
irrespective of the source of recovery, you will be
notified and may resume using the Express Scripts
retail and home delivery programs.
If you need help or have any questions about your prescription drug program, you can call the Plan Office or contact Express Scripts:
www.express-scripts.com or (800) 903-4728
The prescription drug program is designed to cover those prescriptions and medicines that, under state or federal law, require a doctor's prescription. However, the Plan reserves the right to restrict prescription drug coverage to one retail network pharmacy or to deny coverage for individual drugs. If a restriction is imposed, the home delivery pharmacy service option is not available. Listed below are certain items which are not covered: