Prescription Drug Benefits

This plan allows an individual to purchase prescription drugs through two convenient prescription drug programs. One program allows the individual to purchase prescription drugs from a large, nationwide network of retail pharmacies with a single copayment for each prescription or refill. The other program allows the individual to purchase prescription drugs through the mail with a single copayment for each prescription or refill. The individual may purchase covered prescription drugs at pharmacies that do not participate in the program but it is more expensive for the individual and the plan. The two drug programs are described below.

Benefits are provided for prescription drugs and medicines that are required by federal or state law to be prescribed in writing by a physician or dentist, are in full compliance with Federal Food and Drug Administration (FDA) regulations, bear a label indicating dose, warnings and an assigned prescription number, and are dispensed by a licensed pharmacist. Certain drugs require preauthorization with the Trust Office prior to purchase. Examples of drugs currently requiring preauthorization include injectable medications (except insulin), amphetamines (e.g., Dexedrine and Adderall), Ritalin, Retin-A, and immunosuppressives (e.g., CellCept, Neoral, Sandimmune, and Prograf). This list is subject to change based on FDA guidelines for new and existing drugs.

Medco Health Retail Pharmacy Program

The Medco Health Retail Pharmacy Program is a nationwide network of major pharmacy chains and independent pharmacies. This program is best for short-term care when an individual needs a prescription filled immediately:

• An individual should identify a participating retail pharmacy (participating retail pharmacies generally display the Medco Health decal) in his or her area or contact the Trust Office for assistance.
• The individual should present his or her Drug Identification Card to the pharmacist.
• When the individual buys a covered prescription from a participating retail pharmacy, he or she pays a copayment for each prescription or refill:
  • A $7 copayment for each generic prescription.
  • A $15 copayment for each brand-name prescription listed on the drug program formulary.
  • A $30 copayment for each brand-name prescription not listed on the drug program formulary.
• These prescriptions are not subject to the plan’s annual deductible and no claim form or other paperwork is required.
• Prescription drugs dispensed by a licensed pharmacy are limited to a 30-day supply.

Nonparticipating Pharmacies

An individual may purchase covered prescription drugs at pharmacies that do not participate in the program. When an individual purchases a covered prescription from a nonparticipating pharmacy, he or she must pay full retail price and submit a Prescription Drug Reimbursement Form to Medco Health. Medco Health will reimburse the individual at 100 percent of the “average wholesale price” – the program’s discounted price – less the appropriate copayment, usually within 14 to 20 business days. Claim forms are available from Medco Health.

Medco By Mail

Medco By Mail offers convenience and cost savings on prescription drugs taken on a regular, long-term basis, such as medication to reduce blood pressure or treat respiratory conditions, asthma, diabetes, or high cholesterol:

• When an individual buys a covered prescription through the home delivery service, he or she pays a copayment for each prescription or refill:
  • A $10 copayment for each generic prescription.
  • A $20 copayment for each brand-name prescription listed on the drug program formulary.
  • A $35 copayment for each brand-name prescription not listed on the drug program formulary.
• These prescriptions are not subject to the plan’s annual deductible and no claim form or other paperwork is required.
• This program covers up to a 90-day supply for each prescription drug or refill for a single copayment. An individual can submit authorized refills as early as 30 days before his or her current prescription runs out.
• Special envelopes for ordering prescription drugs through the mail-order program are available from the Trust Office.
• Prescriptions will be processed promptly, usually within 48 hours of receipt. After processing, please allow 3 to 5 days for normal mail delivery.

Certain drugs are temperature or motion sensitive and cannot be ordered through the home delivery service.

Preferred Prescriptions Incentive Formulary

The prescription drug programs include an incentive formulary. A formulary is a list of commonly prescribed medications that are preferred based on their clinical effectiveness and affordability. Use of a formulary drug is encouraged through lower copayments.

Sometimes an individual’s physician may prescribe a medication when a formulary preferred brand or generic alternative drug is available, including in some cases, a prescription to be dispensed as written. As part of the prescription drug program, the pharmacist may discuss with an individual’s physician whether an alternative drug listed on the formulary might be appropriate for the individual. If the individual’s physician agrees, the prescription will be filled with the alternative drug. Confirmation will be sent to the individual’s physician explaining the change. The individual should let his or her physician know if he or she has any questions about a change in prescription. The individual’s physician always makes the final decision on all medications and the individual can always choose to keep the original prescription drug. However, an individual saves money if a generic or brand-name formulary drug is prescribed, and if the home delivery pharmacy service is used.

Participating and nonparticipating pharmacies or mail-order benefits are not provided for:

1. Prescription or nonprescription vitamins, nutritional supplements or cosmetics.
2. Drugs or medications furnished by a physician or dentist, or drugs dispensed during an inpatient admission by a hospital, skilled nursing facility, sanatorium, or other facility.
3. Over-the-counter (nonlegend) drugs, meaning drugs for which a physician’s prescription is not required by law, except as provided for under Tobacco Cessation Program.
4. Fertility drugs.
5. Prescriptions used to treat impotence, except as provided for under Erectile Dysfunction.
6. Weight reduction drugs.
7. Infusion therapy, except as provided for under Infusion Therapy.
8. Fluoride and other dental-related medications.
9. Smoking deterrents, except as provided for under Tobacco Cessation Program.
10. Delivery or handling charges.
11. Prescriptions filled in excess of the number prescribed by the physician or covered by an individual’s primary prescription drug program (based on this plan’s coordination of benefit rules) when this plan is secondary; prescriptions prescribed either by someone who is not allowed by the state to prescribe such prescriptions or by a provider who is not covered under this plan; or any refill after one year from the date of the physician’s order.
12. Appliances, devices and other non-drug items including, but not limited to, therapeutic devices and artificial appliances, except as provided for under Medical Supplies and Prosthetic Devices and Artificial Limbs.
13. Experimental or investigative drugs including compounded medications for non-FDA approved use. This exclusion includes drugs that are the subject of an on-going phase I, II or III clinical trial or are otherwise under study to determine their maximum tolerated dose, their toxicity, their safety, their efficacy, or their efficacy as compared with a standard means of treatment.
14. Drugs that are not medically necessary or clinically proven for the treatment of an illness, injury or other covered condition.
15. Drugs or medications for which reimbursement is provided by any federal government, state, county, municipality, or special district, or Medicare.
16. Drugs prescribed for chemical dependency, except as provided for under Chemical Dependency.
17. Biologicals, blood, or blood plasma, except as provided for under Blood.
18. Drugs for cosmetic purposes.
19. Antigen and allergy vaccines or serums, except as provided for under Physician Services.
20. Immunizing agents, except as provided for under Preventive Care.