Your Prescription Drug Program consists of:
The prescription drug program is completely sepa-rate from the Comprehensive Medical Benefit (your medical benefit). Your pharmacy co-pays do not apply to your out-of-pocket limit amount under the Comprehensive Medical Benefit.
When you (or a covered dependent) have a prescription to be filled, the prescription must be filled by a pharmacy that participates in the drug card program, or at the Sav-Rx mail-order pharmacy.
Be sure to show your drug card to the pharmacist at the time the prescription is filled.
The Plan pays no benefits for prescriptions filled by pharmacies that do not participate in the Prescription Drug Program.
You pay the following percentage co-pays for your covered prescription drug charges. The same percentages apply to retail, mail and Walgreens walk-in purchases:
|$5 minimum/$200 maximum co-pay
A formulary is a list of brand name drugs that have been evaluated by physicians and pharmacists, and have been determined to be the most effective treatments for most patients. These drugs have also been determined to be reasonably priced.
Lifestyle drugs are:
PPIs and NSAHs are not covered unless Med-Care has reviewed them for medical necessity and pre-authorized their purchase. It will rarely be medically necessary for a patient to use a prescription PPI or NSAH because there are effective over-the-counter (OTC) versions available. If Med-Care pre-authorizes a PPI or NSAH, Plan benefits will be paid the same as any other lifestyle drug.
YOU PAY EXTRA IF YOU DON’T ALLOW GENERIC SUBSTITUTION
If you chose a brand name drug when a generic equivalent is available, you will be responsible for the difference in cost between the brand name drug and the generic equivalent in addition to your co-pay. The cost difference that you pay does not apply to the Rx out-of-pocket limit.
If the amount of a covered person’s prescription drug co-pays total $3,000 during a calendar year, the Plan will pay 100% of the cost of that person’s covered prescription drugs during the remainder of that year.
A $5,000-per-year family out-of-pocket limit applies to the Active Plan. The Plan’s payment percentage will increase to 100% for you and your dependents during the remainder of a calendar year during which two or more family members have $5,000 applied to their individual limits. (The family out-of-pocket limit does not apply to the Retiree Plan since children are not covered under that plan.)
All prescription drugs that Sav-Rx classifies as “specialty pharmaceuticals” will require prior authorization and utilization review by Sav-Rx to ensure that they are being prescribed for an appropriate patient and condition at an acceptable dose and quantity.
Specialty pharmaceuticals must be purchased through the Sav-Rx Mail Order Pharmacy. You will be allowed one retail fill, but all subsequent fills must be through the Sav-Rx Mail Order Pharmacy. Sav-Rx may limit the initial quantity. Each fill of a specialty pharmaceutical will be limited to a 30-day supply to prevent wasting due to dose changes or therapy discontinuation.
If you or a covered dependent need more than two refills for a short-term prescription, or if a prescription is for a long-term or maintenance drug, you should use the mail-order program.
If your doctor prescribes a new medication to be taken for more than 30 days, ask him to give you two prescriptions:
Viagra and similar prescription erectile dysfunction drugs are covered under the mail-order program only if the drugs are determined by the Fund Office to be medically necessary. With respect to erectile dysfunction drugs, “medically necessary” means that the patient’s impotence is caused by an under-lying physical condition such as diabetes, a non-occupational injury, or a circulatory or neurological disorder. Pre-approval must be obtained from the Fund Office before Sav-Rx will fill the prescription. If pre-approval has been obtained, you can obtain the quantity of drugs prescribed up to a maximum of 72 tablets per calendar year.
Drug manufacturers and other groups often provide co-pay assistance coupons to help patients lower their costs for the most expensive medications.
If you are taking or are newly prescribed a drug selected for this program, Sav-Rx will facilitate your enrollment into the available coupon program. Sav-Rx will contact you – usually by telephone – and explain what steps you need to take. It is important that you follow the steps outlined by Sav-Rx to maintain or reduce your out-of-pocket expenses and avoid therapy disruption.
Affected medications have been placed on a separate co-pay tier with a variable co-pay. The current $200 maximum co-pay will not ap-ply, and the coupon value will be distributed be-tween you and the Plan. Your co-pay will depend on the amount of the assistance available (your co-pay will still be subject to the current $5 minimum). Your actual co-pay amount will apply to your pre-scription drug out-of-pocket limit.
The important thing to know is that you will not pay more than you would have paid in the absence of this program, but you must follow the instructions provided by Sav-Rx to take ad-vantage of the savings.
The Plan and Sav-Rx have a special arrangement with Walgreens that allows you to purchase your long-term and maintenance medications at any local Walgreens. Your Sav-Rx prescription card must be shown to the Walgreens pharmacist at the time the prescription is filled. All the other rules applicable to the regular mail-order program apply to the walk-in program.
If your dependent spouse or child has primary coverage for drugs under another insurance plan, they are not entitled to obtain prescription drugs under the drug card program.
Except for certain diabetic drugs and supplies, only “legend” drugs may be obtained through this program. Legend drugs are those that can be obtained only with a doctor’s prescription.
In addition, the Plan excludes:
Dispensing time limits and days supply limits may also apply. For example, you cannot purchase a refill until 75% of the prior supply has been used. Other limits may be based on the manufacturer’s recommended dosage and duration of therapy, FDA recommendations, federal or state law, or clinical determinations made by Sav-Rx.
In addition, note that high-cost medications and specialty drugs require prior authorization by clinical personnel at Sav-Rx and/or Med-Care Management. The Plan may exclude a drug if there are less expensive but clinically appropriate alternatives available, or if the drug therapy is experimental (unproven), off-label, or not medically necessary or appropriate.
If you have any questions about your prescription drug program, call Sav-Rx toll-free at 1 (800) 228-3108. You should also call Sav-Rx if you need a pre-scription drug card, a list of participating pharmacies or a formulary list. The list will be provided at no cost.