Share a Clear View. El Paso Children's Hospital. Printed on:

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1 Share a Clear View El Paso Children's Hospital Printed on:

2 Share a Clear View NAVITUS CUSTOMER CARE HOURS: 24 Hours a Day 7 Days a Week (toll-free) TTY (toll-free) 711 MAILING ADDRESS: Navitus Health Solutions P.O. Box 999 Appleton, WI WEBSITE:

3 YOUR PHARMACY BENEFIT Welcome to Navitus Health Solutions, the pharmacy benefit manager for Preferred Administrators. We re committed to lowering drug costs, improving health and delivering superior service. This booklet contains important information about your pharmacy benefit. We look forward to serving you! Pharmacy Benefit Schedule 1 Filling Your Prescription 4 Formulary Facts 6 Frequently Asked Questions 8 Common Terms 15

4 PHARMACY BENEFIT SCHEDULE BENEFIT EFFECTIVE DATE October 1, 2017 BENEFIT TYPE Three-Tier Pharmacy Benefit DAYS SUPPLY DISPENSED Participating Retail Pharmacy Specialty Pharmacy UMC Preferred Pharmacy ECH1 Up to 30 Days Up to 30 Days Up to 90 Days BENEFIT STRUCTURE Tier Level Tier 1 Participating Retail Pharmacy $25 copay after $50 deductible UMC Preferred Pharmacy $5 copay after $50 deductible Specialty Pharmacy Applies to Out-of- Pocket Maximum Yes Tier 2 $45 copay after $50 deductible $25 copay after $50 deductible Yes Tier 3 $70 copay after $50 deductible $50 copay after $50 deductible Yes Specialty $50 copay after $50 deductible Yes ANNUAL RX DEDUCTIBLE Individual Deductible $50 N

5 ANNUAL OUT-OF-POCKET MAXIMUM Individual Maximum $6,000 Family Maximum $12,000 ADDITIONAL COVERAGE INFORMATION Formulary Smoking cessation products are covered with a quantity limit of 180 days per calendar year. These include formulary over-the-counter products. PENALTY FOR BRAND WHEN GENERIC AVAILABLE Preferred Administrators urges employees to use generic drugs when a generic is available. If your physician specifies that you use a brand name drug, you will pay the appropriate coinsurance. If you request the brand name when a generic is available, you will pay the appropriate coinsurance plus the difference in cost between the brand and generic. Penalty payments do not count toward the Annual Out-of-Pocket Maximum. RXCENTS (TABLET SPLITTING) This program is part of your pharmacy benefit and is voluntary. This program allows members to pay only one-half of their usual copay for certain drugs. NAVITUS SPECIALTY PHARMACY The Navitus SpecialtyRx Program serves members who are taking medicine(s) for certain chronic illnesses or complex diseases. This program is part of your pharmacy benefit and is mandatory. Specialty medications must be purchased at University Medical Center (UMC) pharmacy at first. If not available, then they must be purchased through Lumicera Health Services. These medications will include a 30-day supply with a $50.00 copay and a $50.00 deductible per plan year.

6 EXCLUSIONS (NOT COVERED) Any product dispensed for the purpose of appetite suppression and other weight loss products. (Any FDA approved prescriptions for weight loss and/or appetite suppression.) Charges for medications for the treatment of erectile dysfunction. Charges for medications obtained through a discount program or over the Internet, unless Prior Authorized by the PBM. Charges for supplies or medications without a doctor s prescription order. Coverage for Prescription Drug Products for the amount dispensed (days supply or quantity limit) that exceeds the supply limit. Drugs used for cosmetic purposes. (Charges for cosmetic drug treatments.) Experimental, Investigational or Unproven Services and medications; drugs used for experimental indications and/or dosage regimens. Infertility and fertility medications. New Prescription Drug Products and/or new dosage forms until the date they are reviewed and assigned to a tier by our Pharmacy and Therapeutics (P&T) Committee. Prescription Drug Products dispensed outside the United States, except as required for Emergency treatment. All over-the-counter drugs, unless designated as covered by the Pharmacy Benefit Manager (PBM).

7 FILLING YOUR PRESCRIPTION Filling Your Prescription at a Network Pharmacy Using Your Pharmacy Benefit ID Card The first step to filling your prescription is deciding on a participating pharmacy. In most cases, you can still use your current pharmacy. There is a complete list on the member website. Information on how to access the member website can be found in the Frequently Asked Questions section of this booklet. Your new pharmacy benefit ID cards are included on the back cover of this booklet. Remove and retain your ID cards for use at the pharmacy. You ll need them each time you fill your prescriptions. The cards contain information the pharmacy needs to process your prescription. To determine your copay before going to the pharmacy, consult your Pharmacy Benefit Schedule or call customer care.

8 Submitting a Claim In an emergency, you may need to request reimbursement for prescriptions that you have filled and paid for yourself. To submit a claim, you must provide specific information about the prescription, the reason you are requesting reimbursement, and any payments made by primary insurers. Complete the appropriate claim form and mail it along with the receipt to: Navitus Health Solutions Operations Division - Claims P.O. Box 999, Appleton, WI Claim forms are available on the member website or by calling customer care.

9 FORMULARY FACTS About Drug Formularies Selecting Drugs for Your Formulary The formulary is a comprehensive list of preferred drugs chosen on the basis of quality and effi cacy by a committee of physicians and pharmacists. The drug formulary serves as a guide for the provider community by identifying which drugs are covered. It is updated regularly and includes brand name and generic drugs. An independent group of physicians and pharmacists meets regularly during the year to review and select drugs for your formulary that will be safe, effective and affordable. The committee assesses drugs based on their therapeutic value, side effects and cost compared to similar medications. Based on the committee s review of new and existing drugs, your formulary is evaluated to ensure it is upto-date.

10 Checking Your Formulary Changes to Your Formulary Your formulary is on the Navitus website through your member portal. You can access your member portal by going to > Members > Member Login. You may search the formulary for a specifi c drug. You can also browse alphabetically or by category of use. Also included is information about which drug products need prior authorization and/ or have quantity limits. The formulary is a condensed list and does not list every covered drug. The coverage or tier for each drug product is noted on the formulary. But the dollar amount you pay for each medication is not listed. See the Pharmacy Benefi t Schedule included in this booklet for more information, including the cost share amount you pay for each drug. Your formulary is evaluated on an ongoing basis, and could change. Navitus does not send separate notices if a brand-name drug becomes available as a generic drug. The pharmacist usually tells you this information when you fi ll your next prescription. If you have more questions about the formulary or your cost share, please contact Navitus Customer Care.

11 FREQUENTLY ASKED QUESTIONS What is Navitus? What is a Pharmacy Benefit Manager? Who do I contact with questions about my pharmacy benefit (such as preferred drug list, claims, participating pharmacies, etc.)? Navitus Health Solutions is your Pharmacy Benefits Manager (PBM). A PBM directs prescription drug programs and processes prescription claims by negotiating drug costs with manufacturers, contracting with pharmacies and building and maintaining drug formularies. These cost saving strategies will lower drug costs and promote good member health. Your preferred drug list, list of participating pharmacies and other information about your pharmacy benefit can be found on www. navitus.com > Members > Member Login. You can also call Navitus Customer Care toll-free at with questions about your pharmacy benefit.

12 How do I find information about my benefit online? Where can I find my formulary? What is a Retail pharmacy? Can I use my health plan card to fill prescriptions at my pharmacy? Your health comes first, and Navi-Gate can help you with your pharmacy benefit questions and more. Navi-Gate for Members provides you with online access to a wealth of information to help you better understand your prescription drug benefits, add convenience to your life and help identify cost-saving options. Whether it is helping you find a local pharmacy or reviewing your medication profile, Navi- Gate will provide you with the information to take control of your personal health. You can sign up for Navi-Gate for Members by visiting Login. The list of drugs covered by your benefit is available on our website at > Members > Member Login. A Retail pharmacy is any Navitus Network Pharmacy covering day supply between 1-30 days. Any pharmacy willing to contract with Navitus is included in this network. A list of participating retail pharmacies and other information about your pharmacy benefit can be found on > Members > Member Login. No, you are required to present a Navitus ID card to the pharmacy when you fill a prescription. Your cards are affixed to this booklet s back cover. You can request replacement cards from Navitus by calling Customer Care toll-free at

13 Who do I call to change my ID card information or request additional cards? When can I refill my prescription? How much will I pay at the pharmacy? How do I fill a prescription when I travel for business or vacation? Please call Navitus Customer Care toll free at if any information on your ID card needs to be changed. We will mail you a new ID card, and you should receive it within 7-10 calendar days from the date of your request. Your prescription can be refilled at a retail pharmacy when approximately three-quarters or 75% of the prescription has been taken. You can use the pharmacy benefit information in this booklet to find out how much you will pay for different medications at the pharmacy. If you have questions about how to get this information, please contact Navitus Customer Care toll-free at If you are traveling for less than one month, any Navitus Network Pharmacy can arrange in advance for you to take an extra one-month supply. A copayment will apply. Visit for complete instructions on filling prescriptions while traveling, or contact Customer Care toll-free at If you are traveling for more than one month, you can request that your pharmacy transfer your prescription order to a U.S. network pharmacy located in the area where you will be traveling.

14 Can prescriptions be mailed to me if I m outside of the United States? How do I use the Navitus SpecialtyRx program? Prescriptions cannot legally be mailed from the mail order pharmacy or any pharmacy in the United States to locations outside of the country, except for U.S. territories, protectorates and military installations. Navitus SpecialtyRx works with Lumicera to offer services with the highest standard of care. You will get one-on-one service with skilled pharmacists. They will answer questions about side effects and give advice to help you stay on course with your treatment. With Navitus SpecialtyRx, delivery of your specialty medications is free, and right to your door or prescriber s office via FedEx. Local courier service is available for emergency, same day medication needs. To start using Navitus SpecialtyRx, please call toll-free We will work with your prescriber for current or new specialty prescriptions.

15 How does the RxCENTS (Tablet Splitting) program work? The Tablet Splitting program saves you money by breaking a higher-strength tablet in half to provide the needed dose. You will receive the same medication and dosage while purchasing fewer tablets and saving on your copay. There are two ways to get started with the Tablet Splitting program: 1. Call your doctor and ask about the RxCENTS program. He or she can update your prescription with your pharmacy. 2. Ask your pharmacist to help change your prescription to one that can be split through the Navitus Tablet Splitting program. Tablet splitting is not required by Navitus, but is simply offered to you as a way to help control costs. If you have any questions, or would like to receive a tablet splitter, please contact Navitus Customer Care toll-free at

16 What is Coordination of Benefits (COB)? How are my COB claims processed? Coordination of Benefits takes place when you have coverage under Navitus and another policy. One of the policies will be your primary coverage and one is your secondary coverage. Claims are first submitted to your primary policy and then to the secondary policy. The secondary policy covers the remaining cost of covered medications up to the allowed amount minus any applicable copayment. At the pharmacy, prescriptions are paid under your primary insurance. To be reimbursed by Navitus for your secondary coverage, you must complete a reimbursement form and submit it to Navitus. Reimbursement forms are available on the Navitus website, www. navitus.com, or by calling Navitus Customer Care toll-free at

17 How do I make a complaint or file an appeal? MAIL Preferred Administrators Attn: Health Services Department 1145 Westmoreland Drive El Paso, TX When you have a concern about a benefit, claim or other service, please call Preferred Administrators at You can submit your complaint in writing, fax or mail. For verbal appeals, a member appeal form will be filled out by phone. Please send this appeal, along with related information from your doctor, to: FAX Preferred Administrators Attn: Health Services Department

18 Copayment/ Coinsurance Formulary COMMON TERMS Refers to that portion of the total prescription cost that the member must pay. A list of drugs that are covered under your benefi t plan. The drugs on your formulary are chosen for your formulary by an independent group of doctors and pharmacists. These experts evaluate drugs based on effectiveness, side-effects, potential for drug interactions, and cost. Drugs that are both clinically sound and cost effective are added to your formulary. Generic Drugs Prescription drugs that have the same active ingredients, same dosage form and strength as their brand-name counterparts. Out-of-Pocket Maximum Over-the- Counter Medication Prescription Drug Prior Authorization Specialty Drug Therapeutic Equivalent The maximum dollar amount the member can pay per contract year. A drug you can buy without a prescription. Any drug you may get by prescription only. Approval from Navitus for coverage of a prescription drug. Drugs, such as self-injectables and biologics, typically used to treat patients with chronic illnesses or complex diseases. Similar drug in the same drug classifi cation used to treat the same condition.

19 Share a Clear View Voice your feedback, concerns or complaints or report errors regarding your prescription drug benefit. We welcome your input and want to hear and act on this information with a polite and quick response. Ensuring quality and safe care, correcting errors, and preventing future issues are top priorities. For a copy of your member rights and responsibilities, please visit your member website or call the Customer Care number listed below. Navitus does not discriminate on the basis of disability in the provision of programs, services or activities. If you need this printed material interpreted or in an alternative format, or need assistance using any of our services, please contact Navitus Customer Care at (toll-free) or 711 (TTY).

20 Preferred Administrators P.O. BOX El Paso, TX B000000