Prescription Drug Coverage

Transcription

1 The Company s medical plans automatically include coverage for prescription drugs which is administered by Envision Pharmaceutical Services, Inc. (Envision Rx) for prescriptions filled at retail pharmacies or Orchard Pharmaceutical Services (Orchard Rx) for mail-order prescriptions. If you participate in the Standard Plan, Enhanced Plan, or Premier Plan, there is no annual deductible to meet before prescription drug benefits are paid. Important terms and phrases used in this summary can be found in the glossary. Be sure you understand the meaning of the terms see Glossary. How Your Prescription Drug Benefits Work You have a choice when you buy prescription drugs. You can purchase your medications: From any retail pharmacy that participates in Envision Rx s network Through the Orchard Rx mail service pharmacy Whether you go to a retail pharmacy or use the Orchard Rx mail service pharmacy, a range of generic and brand-name drugs is covered. However, keep in mind that when you fill a prescription, the pharmacist typically fills your prescription with a generic drug if a generic equivalent is available. Prescriptions filled at an out-of-network pharmacy are not covered by the plan. You will be responsible for paying the full cost of those prescriptions. 63

2 Your Prescription Drug Benefits at a Glance The chart below summarizes your prescription drug benefits available through the Company s medical plans. Feature In-Network Pharmacy Out-of-Network Pharmacy Retail Pharmacy (up to a 30-day supply) Generic Drug You pay a $5 copay Formulary Brand Drug Non-Formulary Brand Drug You pay a $30 copay You pay a $50 copay Orchard Rx Mail Service Pharmacy (up to a 90-day supply) Generic Drug You pay a $10 copay Formulary Brand Drug Non-Formulary Brand Drug You pay a $60 copay You pay a $100 copay Tobacco Free Program Plan covers prescription medications and over-the-counter treatments when used as a means for becoming tobacco free. The tobacco free treatment has a $1,000 per person per lifetime maximum How to Use Your Prescription Drug Benefits Remember Prescriptions filled at an out-of-network pharmacy are not covered by the plan. You will be responsible for paying the full cost of those prescriptions. When you fill a prescription, the pharmacist typically fills your prescription with a generic drug if a generic equivalent is available. If you choose to purchase a brand drug rather than the generic equivalent, you will pay the brand drug cost, even if your doctor specifies that the generic equivalent should not be dispensed. If a generic equivalent is not available, a brand drug that is on the Envision Rx list of preferred medications (called a formulary drug ) will save you money compared to a brand drug that is not on the formulary drug list. If a drug does not have an alternative on the formulary list, you will pay the higher, non-formulary brand drug cost. For a copy of the formulary list, contact Envision Rx. (For the phone number and website, see Contact Information.) 64

3 About Formulary Drugs Envision Rx has a committee that meets regularly to review information on the safety and effectiveness of each drug considered for addition to the formulary. Envision Rx also conducts an annual review of all drugs listed on the formulary, in addition to considering new drugs, generics, and formulations for the formulary throughout the year. Drugs under consideration are subject to rigorous clinical analysis of their effectiveness, safety, side effects, drug-to-drug interactions, and therapeutic class. The committee then makes a final determination regarding the drugs that are included in Envision Rx s formulary. In-Network Retail Pharmacies When you go to an in-network retail pharmacy to fill your prescription, simply show your medical ID card. The amount you pay depends on whether you receive a generic drug, formulary brand drug, or non-formulary brand drug. You can receive up to a 30-day supply of medication through an in-network retail pharmacy. Keep in mind that if you use a retail pharmacy that does not participate in the Envision Rx network, you will not receive coverage and you will be responsible for the full cost of the drug. Please note: If you don t show your medical ID card when filling a prescription, you will pay the full cost of the drug. If you are a new employee and you don t have your ID card yet, you can go back to the pharmacist within 7 days to receive any applicable refund. You may also submit a claim for reimbursement. Orchard Rx Mail Service Pharmacy To locate an in-network pharmacy, visit Envision Rx s website at to access the online pharmacy directory. You can also call Envision Rx directly at The directory lists all of Envision Rx s in-network pharmacies in your home ZIP code area. You can order maintenance prescriptions through the Orchard Rx mail service pharmacy. The amount you pay depends on whether you receive a generic drug, formulary brand drug, or non-formulary brand drug. You can receive up to a 90-day supply of medication through the Orchard Rx mail service pharmacy. To order a prescription through the Orchard Rx mail service pharmacy, complete the Order and Patient Profile Form, available on the website you only need to complete the patient profile information once. (For the phone number and website, see Contact Information.) To submit your prescription, you have three options: Your doctor can fax your prescription to the Orchard Rx mail service pharmacy For new prescriptions: For prescriptions from the specialty pharmacy:

4 Your doctor can phone in the prescription to You can mail the written prescription from your doctor You will need to send the Orchard Rx mail service pharmacy your applicable copay. The address for mailing prescriptions or sending your copay is: Orchard Rx Pharmaceutical Services P.O. Box 3094 North Canton, OH You will receive your medication within approximately 7 10 days from the date the Orchard Rx mail service pharmacy receives your order. If you need your medication sooner, ask your doctor to write two prescriptions: One for up to a 30-day supply to be filled immediately at an Envision Rx in-network retail pharmacy (and paid at the regular retail copay or coinsurance that applies) One that you can send to the Orchard Rx mail service pharmacy for an additional 90-day supply at the applicable copay or coinsurance level How to Pay for Prescription Drugs Deductibles, copayments, and coinsurance will not be reduced by any discounts, rebates, or other funds received by Envision Rx, Orchard Rxand/or the plan from drug manufacturers or similar vendors. Certain supplies and equipment obtained at an Envision Rx in-network retail pharmacy or through the Orchard Rx mail service pharmacy (such as those for diabetes and asthma, but excluding diabetic test strips) are covered without any cost. Contact Envision Rx to determine the approved supplies that are covered without cost. (For the phone number and website, see Contact Information.) COPAYS A copay is the dollar amount you pay for generic and brand drugs through an Envision Rx in-network retail pharmacy or through the Orchard Rx mail service pharmacy. You pay the applicable copay for each covered prescription that you purchase. How Prior Authorization Works Some prescription drugs require prior authorization from Envision Rx before they can be dispensed, to ensure that the medication is an appropriate treatment for your condition. Prior authorization may also be required for the prescribed quantities of certain medications. When you fill a prescription that requires prior authorization, in-network pharmacists will be notified and will contact Envision Rx on your behalf. If authorization is granted, the pharmacist will fill your prescription. If authorization is denied, you have the right to appeal Envision Rx s decision. (See Claims Review and Appeals Procedures in Rules, Regulations, and Administrative Information for more information.) Prior authorization of a drug generally is valid for one year. 66

5 To find the list of drugs requiring prior authorization, go to or call Envision Rx directly at Knowing What Is Covered and What Is Not It is possible that some prescription drugs may not be covered under the Company s medical plans. Please note: If certain supplies, equipment, or appliances are not obtained through an Envision Rx in-network retail pharmacy or the Orchard Rx mail service pharmacy, they may be covered under the medical plan as medical supplies, durable medical equipment, or appliances instead of as prescription drug benefits. Contact HDP to determine whether supplies, equipment, or appliances are covered under the medical plan. (For the phone number and website, see Contact Information.) ELIGIBLE EXPENSES The following expenses are covered through the prescription drug plan: Human growth hormones Injectable insulin and syringes used for administration of insulin Injectables Oral contraceptives (covered for associates and their spouses only) Prescription legend drugs Prescription medications and over-the-counter treatments when used as a means for becoming tobacco free. The tobacco free treatment has a $1,000 per person per lifetime maximum Therapeutic substitution of drugs INELIGIBLE EXPENSES The following expenses are not covered through the prescription drug plan: Any drug that is primarily for weight loss, except drugs for the treatment of morbid obesity Any new FDA-approved drug product or technology (including but not limited to medications, medical supplies, or devices) available in the marketplace for dispensing by the appropriate source for the product or technology, including but not limited to pharmacies, for the first six months after the product or technology received FDA new-drug approval or other applicable FDA approval. (The plan may, at its sole discretion, waive this exclusion for a specific new FDA-approved drug product or technology in whole or in part) Charges for the administration of any drug 67

6 Drugs consumed at the time and place where dispensed or where the prescription is issued, including but not limited to samples provided by a physician Drugs dispensed by out-of-network pharmacies Drugs for treatment of sexual or erectile dysfunctions or inadequacies, regardless of origin or cause (except for Viagra as otherwise specified) Drugs in quantities exceeding the quantity prescribed, or any refill dispensed later than one year after the date of the original prescription Drugs in quantities that exceed the limits established by the plan Drugs not requiring a prescription by federal law (including drugs requiring a prescription by state law, but not by federal law), except for injectable insulin Fertility drugs Off-label use, except as otherwise prohibited by law Oral contraceptives (except for associates and their spouse) and all other contraceptives, including but not limited to contraceptive devices Oral immunizations, and biologicals, although they are federal legend drugs, which are payable as medical supplies based on where the service is performed or the item is obtained Over-the-counter drugs, or prescription legend drugs with over-the-counter equivalents, except when used as a means for becoming tobacco free Vitamins, except for pre-natal vitamins Filing Claims You do not need to file a claim when you use an Envision Rx in-network pharmacy or the Orchard Rx mail service pharmacy. Remember: Prescriptions filled at an out-of-network pharmacy are not covered by the plan. You will be responsible for paying the full cost of those prescriptions. For more information about filing claims and the claims appeal process, refer to Claims Review and Appeals Procedures in Rules, Regulations, and Administrative Information. 68