Co-payment Summary Co-payment is the dollar amount paid by the member for each covered prescription

Transcription

1 Prescription Benefit Plan Summary For City of Dubuque, Iowa Plan Year 2015 Co-payment Summary Co-payment is the dollar amount paid by the member for each covered prescription Drug Type Up to 34 Days Supply Co-pay Up to 90 day supply Copay Generic $2 $4 Preferred/Formulary Brand $5 $10 Non-Preferred/Non-Formulary $15 $30 Quantity Limitations/Dispensing Policy Summary Generally, the maximum quantity of medication a member can receive with a single prescription. Certain medications may have additional restrictions on the quantity. Mail Order Prescriptions: 90 day supply. Refills Amount of time elapsed since the last prescription was filled before a refill is allowed Retail: At least 75 percent of medication has been taken or 25 percent is remaining Mail: 34 days remaining Ancillary/Generic Drug Policy Ancillary Charge IDAW: A charge in addition to the co-payment and/or deductible amount which the member is required to pay to a participating pharmacy for a covered brand-name prescription drug for which a generic substitute is available. If the physician writes dispense as written (DAW) on the prescription for a brand name drug, with a generic equivalent available, the member will be charged the preferred/formulary brand co-pay or non preferred/non-formulary brand co-pay depending on the formulary status of the brand drug. If the physician does not write dispense as written (DAW), the member will be subject to the ancillary charge, the applicable co-pay plus the difference in cost between the brand and the generic product. Formulary A list of preferred medications in your pharmacy benefit plan. The formulary drug list is used as a guide for determining the amount that you pay as a co-payment for each prescription, with drugs listed on the formulary typically available at a lower co-payment to the member. When to Use The most efficient way to use your retail pharmacy benefit is to present your member ID card at a participating retail pharmacy. Your retail plan should be used for medications required on a short-term basis. When you have a prescription filled at a participating pharmacy, present your member ID card to the pharmacist, who will use an automated system to verify your coverage and prescription cost. City of Dubuque Prescription Benefit Plan Summary 2015 Page 1

2 Step Therapy Program This program ensures that members receive the most cost effective medications (generic or covered OTC) prior to the Plan approving brand medications. Call for the most current information. Drug Coverage The prescription program provides coverage for legend (prescription) drugs. Below is a guideline of benefit coverage and exclusions: Covered Items See attached plan literals for drug coverage detail. Prescription Medication, injectable insulin, all insulin syringes, needles and oral contraceptives listed on the Plan Drug Formulary are covered drugs under this contract. Covered drugs must be prescribed by a Participating Prescriber and dispensed by a Participating Network Pharmacy as noted below. Prescriptions must be dispensed in accordance with the Plan Drug Formulary, Step Therapy Programs and Maximum Retail Allowable List. Federal Legend Drugs Compounded prescriptions Contraceptives - Non Injectable forms (oral, patch, emergency) Contraceptives Injectable forms (Depo-Provera, Medroxyprogesterone Acetate, Depo- SubQ Provera) Insulin & non-insulin syringes, needles & devices Legend vitamins, multivitamins & supplemental vitamins Estrogen Legend Hemopoetic Agents Meclizine (legend and non-legend strengths) Bee Sting Kits Smoking Cessation products Exclusions See attached plan literals for drug coverage detail. Under this benefit, the following drugs are excluded except as specified: 1. Any drug for which reimbursement is available under any other group program or government program. 2. Diabetic supplies (other than injectable insulin, all insulin syringes and needles) i.e., Testape, chemstrips, etc. are covered under the Durable Medical Equipment provision of the Medical Plan. 3. Any charge for appetite suppressants (e.g., diet pills), or drugs or supplies associated with weight loss, nutritional diet supplements, hair growth stimulants (Minoxidil), Methoxaselen and medications for Cosmetic purposes only (e.g., Retin A for aging or Rogaine) and drugs for athletic performance, (e.g., steroids). 4. Drugs dispensed from or by any Hospital, Extended Care Facility, clinic, or other institution to an Inpatient or Outpatient; such drugs are covered by the medical portion of the Plan. City of Dubuque Prescription Benefit Plan Summary 2015 Page 2

3 5. Drugs, compounds, or dosage regimens determined by the Plan, to be Investigational, Experimental or unapproved by the FDA, or drugs or compounded prescriptions without an NDC number or with ingredients not requiring a Physician s authorization by state or federal law. 6. Medications available over-the-counter (OTC) that do not require a Physician's authorization by state or federal law and any Prescription Medication that is available as an OTC medication or for which there is an OTC alternative. Except in the specific cases where the Plan has adopted guidelines covering a specified OTC Drug. This includes, but is not limited to, OTC medications that, when taken in sufficient quantity, are equal in strength to the prescription ( legend ) version(s) of the same medications. 7. Replacement medications resulting from loss, theft or breakage. 8. Medication requested or required for travel. 9. Life enhancing medications including but not limited to erectile dysfunction treatments (e.g. Viagra, Levitra, Cialis). 10. Drugs dispensed by other than a retail pharmacy or the Plan s approved mail-order provider. 11. Fertility drugs. 12. Any prescription refilled in excess of the number specified by a Participating Prescriber, or any refill dispensed one year from the Participating Prescriber s original order. 13. Medications with no approved FDA indications (e.g. Yohimbine). 14. Prescriptions written for non-covered Services under the Plan (e.g. those written by a Dentist or oral surgeon relating to non-covered dental services). 15. A prescription that exceeds a 34-day supply, unless the drug is listed on the maintenance drug listing. 16. Coverage for which benefits are payable under another program, i.e., Coordination of Benefits, Worker's Compensation. 17. Drugs for which the Pharmacy's Usual and Customary charge is less than the applicable Copayment. Your responsibility will be the actual cost of the prescription. 18. Non-prenatal vitamins 19. Diabetic Glucose Meters. 20. Unit dose medications 21. Photo-Aged Skin Products City of Dubuque Prescription Benefit Plan Summary 2015 Page 3

4 22. Cosmetic injectables 23. Depigmentation products 24. Immunization agents, serums, toxoids & vaccines 25. Allergens 26. Antiretrovirals 27. IV administered drugs 28. Durable Medical Equipment & Devices 29. Any charge for administration of drugs. Days Supply At retail pharmacies, you may purchase up to a 34-day supply of most prescription medications. There may be limitations on some prescriptions, such as controlled medications, subject to state and federal dispensing limitations. Co-payment Different co-payments may apply for certain medications. For brand-name medications: For medications that are on your plan's preferred drug list: Your co-payment is $5.00. For medications that are not on your plan's preferred drug list: Your co-payment is $ For generic medications: Your co-payment is $2.00. For brand-name medications when a generic is available: For medications that are on your plan's preferred drug list: Your co-payment is $5.00. If the patient requests a brand-name medication when a generic equivalent is available you will be responsible for your brand co-payment plus the difference in price between the brand-name medication and its generic equivalent. For medications that are not on your plan's preferred drug list: Your co-payment is $ If the patient requests a brand-name medication when a generic equivalent is available you will be responsible for your brand co-payment plus the difference in price between the brand-name medication and its generic equivalent. City of Dubuque Prescription Benefit Plan Summary 2015 Page 4

5 Mail Order Prescription Drug Program The mail order program allows you to order up to a 90-day supply of maintenance prescriptions when prescribed by a Participating Prescriber. Your prescription is filled, shipped and delivered to your home within two weeks, unless you request overnight or second-day delivery for an additional charge. When you utilize the mail order program, you will receive up to a 90-day supply of your maintenance medication for the equivalent of two Copayments. To view the maintenance drug listing call Express Scripts at Specialty Pharmacies Some prescription drugs are called "specialty medications". Specialty medications usually have to be stored or handled in special ways and you may not be able to get them from most pharmacies. People take specialty medications for complex, chronic health conditions like Multiple Sclerosis or Rheumatoid Arthritis. If you're taking a specialty medication, there are services available for you through our specialty pharmacy at no additional charge: You can order refills and check the status of your specialty medication orders anytime online. You have access to our complete specialty pharmacy inventory with medications that may not be readily available at other pharmacies. Your specialty medications are delivered directly to you or your doctor, as allowed by applicable law. You receive the supplies you need to administer your medications. Our clinically based care management programs - which include consultation with your doctor - help you get the most benefit from the medications that your doctor has prescribed for you. Our highly trained Patient Care Advocates work closely with you, your physician and your health plan, obtaining prior authorizations, coordinating billing and even contacting you when it's time to refill your prescription. You can request transfer of your existing specialty prescriptions from a retail pharmacy to home delivery online or call Coordination of Benefits Coordination of Benefits is the process in which two or more health insurers cover the same person(s) but limit the total benefit payable for a claim to an amount not exceeding the total cost of the claim. If Express Scripts is your secondary benefit, primary claims submitted by the retail pharmacy or primary paper claims submitted by you will not be covered. If you have sent the prescriptions through mail order and Express Scripts is your secondary benefit, you will be contacted to verify your coverage. City of Dubuque Prescription Benefit Plan Summary 2015 Page 5

6 You may submit a paper claim to be considered for reimbursement under your secondary coverage. The Coordination of Benefit applies to: Your mail-order claims. Your member -submitted paper claims. Your retail pharmacy claims. For further information on Coordination of Benefits or for an explanation on the reimbursement of a claim, please call the Member Service phone number on the back of your card. This information is intended to serve as a general overview of your plan sponsor's prescription benefit program. Please note that the terms of your prescription benefit are subject to change. Please consult your plan sponsor for complete information. Drug Definitions 1. Ancillary Charge. A charge, in addition to the Copayment charge, which the Covered Person is required to pay to a Participating Network Pharmacy for a Prescription Medication, which, through the request of the Covered Person or Participating Prescriber, has been dispensed in non-conformance with the Plan s Maximum Retail Allowable (MRA) list. 2. Brand Name. A drug manufactured and marketed under a trademark or name by a specific drug manufacturer and does not have a generic equivalent 3. Copayment Charge. The specified charge that the Covered Person is required to pay the Participating Network Pharmacy for a Prescription Medication in accordance with this Plan. 4. Covered Person. An Employee, as defined by the Plan, and qualified dependents, which qualify for coverage under this Plan. 5. Drug Formulary. A listing of Prescription Medications which are approved for use by the Plan and which will be dispensed through a Participating Network Pharmacy to Covered Persons. 6. Generic. A medication chemically equivalent to a brand-name drug for which the patent has expired. 7. Maximum Retail Allowable List (MRA List). A list of Prescription Medications that will be covered at a generic product level established by the Plan. This list is distributed to Participating Network Pharmacies and is subject to periodic review and modification by the Plan. 8. Multi-Source Brand - Multi-Source Brand drugs are drugs available from more than one source. Brand name drugs whose patents has expired and are marketed in generic form from different manufacturers or more than one company manufactures the name brand drug. 9. Non-Preferred Brand - A Brand drug which is not included on an ESI Formulary. City of Dubuque Prescription Benefit Plan Summary 2015 Page 6

7 10. Participating Network Pharmacy. A Pharmacy which has entered into a service agreement to provide Prescription Medication services to Covered Persons. 11. Participating Prescriber. A Participating Provider who is duly licensed by the state to prescribe medications in the ordinary course of his or her professional practice and who is a Participating Physician as defined by the Plan. 12. Plan. Means Medical Associates Clinic, P.C. Medical Health Care Plan. 13. Plan s Usual and Customary Charge. The lesser of the actual charge for the drug or 90% of the average wholesale price as determined by the national drug database subscribed to by the Plan s claims processor. 14. Preferred Brand - A Brand drug selected for inclusion on an ESI Formulary. 15. Prescription Medication. A drug which has been approved by the Food and Drug Administration and which can, under federal or state law, be dispensed only pursuant to a Prescription Order (a legend medication). 16. Prescription Order or Refill. The authorization for a Prescription Medication issued by a Participating Prescriber who is duly licensed to make such an authorization in the ordinary course of his or her professional practice. 17. Single Source Brand - Single Source Brand drugs are unique drugs under patent protection, marketed only by one manufacturer. A brand-name drug with no generic equivalents available. City of Dubuque Prescription Benefit Plan Summary 2015 Page 7

8 Plan T05 YRS COVERED DRUGS: Federal Legend Drugs State Restricted Drugs Compounded Medications of which at least one ingredient is a legend drug Insulin Federal Legend Non-Drugs Investigational Drugs S Depo-Provera/Depo-SubQProvera (Std) C [OTC and Legend] EBD EBD: SYRINGES, NEEDLES & DEVICES C [OTC and Legend] EBD00043 EBD: NON-INSULIN SYRINGES C [OTC and Legend] MECLIZINE 12.5 (RX-OTC): GC 4905 & STR 32D = & DF 29 C EBD00025 & DC F : LEGEND THERAPEUTIC VITS C Legend MultiVitamins [EBD00026 & DC=F] C EBD: LEGEND HEMOPOETIC AGENTS EBD00028 C NPS INFLAMTRY CONDTN: STP06139 C PAL00682: SSM NPS ALPHA 1 INHIB 1ST PA C STP06212: SSM NPS ALPHA INHIBITORS COV C EBD00098: EBD: SPECIALTY PA DRUGS C EBD00065 PA ALL BASE LIST C EBD00100: EBD: PROACTIVE PA C EBD00066 PA SUPPLEMENTAL LIST C PAL FLOLAN/REMODULIN C PAL00554: UM PA PHARMACOGENOMICS C NPA00021: ANTIRETROVIRALS C NPA00008: DIAGNOSIS RQD;DC DXX, OPT# EXCLUSIONS: Non-Federal Legend Drugs Non Federal Legend Non-Drugs S Abortifacients (Std) Mifeprex C ESI BOB REPACKAGE LIST (SPS=151) C ESI West Insulin Pump Pended NDC Block C Pended-Implanon C Pended-Nexplanon C T05 DC49_13_YWU C ESI STD UD EXCLUSION DRUGLIST C EBD00004 : DEPIGMENTATION AGENTS C No Active NDCEBD00007 CONT - INJ 30 DAY S Smoking Deterrents (Std, Legend) C EBD00048 EBD FERTILITY REGULATORS - ALL C EBD00002 & DC F: LEGEND HAIR GROWTH AGENTS C EBD00001 EBD PHOTO-AGED SKIN PRODUCTS S Anti-Obesity Preparations (Std, Legend) City of Dubuque Prescription Benefit Plan Summary 2015 Page 8

9 C EBD00049 : IMPOTENCE - INJ and NON INJ S Yohimbine (Std) C NPA19:RHO D IMMUNE GLOB; DC RHO C EBD00022 EBD SERUMS, toxoids, VACCINES C EBD00021 EBD ALLERGENS C MISC DIAGNOSTIC AGENTS (NPA18): [NPA00018] C EBD00060 EBD INJ COSMETICS C EBD00041 EBD: RESPIRATORY THERAP SUPPL S Peak Flow Meters (Std) S Intrauterine Devices (Std) C NPA MISC DEVICES C EBD00044 EBD: OSTOMY SUPPLIES S IV Route Agents SUPER RULES: The drug lists below drive the day supply and/or quantity logic if the drug is found in the covered or prior authorization sections above: S Card and Direct: Pediatric Fluoride Vitamins Drops (Std), up to a 50 day supply C Card and Direct: ACDS 35day, up to a 35 day supply C Card and Direct: ACDS Non-Standard Days Supply 56 Day List, up to a 56 day supply C Card and Direct: Non Standard Days Supply Specialty 42 Day List, up to a 42 day supply C Specialty Standard 180 Day Supply, up to a 180 day supply C Card and Direct: Specialty Std 90 Day Supply Drug List, up to a 90 day supply C SPECIALTY STD DAY SUPPLY DRUG LIST 365, up to a 365 day supply S Specialty Std 120 Day Supply Drug List, up to a 120 day supply S Card and Direct: ESI Non-std 42 Days Supply Drugs, up to a 42 day supply S Card and Direct: ESI Non-std 56 Days Supply Drugs, up to a 56 day supply S Card and Direct: ESI Non-std 90 Days Supply Drugs, up to a 90 day supply S ESI Non-std 91 Days Supply Drugs, up to a 91 day supply S ESI Non-std 120 Days Supply, up to a 120 day supply S ESI Non-std 168 Days Supply Drugs, up to a 168 day supply S ESI Non-std 180days Supply Drugs, up to a 180 day supply S ESI Non-std 365 Days Supply Drugs, up to a 365 day supply C Card and Direct: EBD00064 EBD:ESTROGEN REPLACE-60D, up to a 60 day supply C Card and Direct: EBD00005 EBD CONTRACEPTIVES-NON INJ MONTHLY, up to a 90 day supply S Card and Direct: Intravaginal Contraceptives (Std), up to a 90 day supply City of Dubuque Prescription Benefit Plan Summary 2015 Page 9

10 Super T05 YRS Plan: T05 YRS RRA: ESI SPECIALTY SPE00345 RRA 1 FILL - The RRA maintenance categories of medications are limited to 1 fill. Specialty: Mail Pricing Specialty Subproduct Coverage Limit: The amount of drug which is to be dispensed per prescription or refill will be in quantities prescribed for Card claims: up to 34 days supply; Mail claims: up to 90 days supply; Direct claims: up to 34 days supply. City of Dubuque Prescription Benefit Plan Summary 2015 Page 10