1 New York State Auto Dealers Association Group Insurance Trust (GIT) Prescription Drug Coverage Summary Effective January 1, 2014, all pharmacy coverage will be administered by Express Scripts and its affiliates. If you have questions you may call Express Scripts Member Services 24 hours a day, seven days a week toll free at or you may visit the Express Scripts website at Scripts.com. An Explanation of Certain Terms Prescription Drugs. A prescription drug is any of the following: A drug, biological, or compounded prescription which, by Federal Law, may be dispensed only by prescription and which is required to be labeled "Caution: Federal Law prohibits dispensing without prescription." Diabetic supplies when prescribed and purchased at the same time as insulin. This does not include glucometers and other diabetic equipment, which may be covered under durable medical equipment. Participating Pharmacy (In-Network). A local retail pharmacy, which is party to an agreement with the Claims Administrator to dispense drugs to persons covered under the Plan, but only: While the agreement remains in effect; and When such a pharmacy dispenses a prescription drug under the terms of its agreement with the Claims Administrator. To find a Participating Pharmacy nearest you, call Member Services toll free at or visit the website at Scripts.com to use the online interactive pharmacy locator. When you present your ID Card at a Participating Pharmacy, you are charged according to the Pharmacy Copayment Schedule. If you do not use your prescription card at the Participating Pharmacy, you will be responsible for 100% of the prescription retail price at the time of purchase. You will need to submit a completed claim form to Express Scripts for reimbursement. These forms may be found online. The Plan will not cover any price difference between the amount charged by the pharmacy and the discounted amount that would have been charged if you had presented your ID Card. You will be responsible for this amount in addition to your copayment amount. Non-Participating Pharmacy (Out-of-Network). A pharmacy not party to an agreement with the Claims Administrator, or a pharmacy who is party to such an agreement but who does not dispense prescription drugs in accordance with the terms of that Agreement. If you have a prescription filled at a pharmacy which is not participating, you must pay the pharmacy the full amount of it s bill and submit a claim form with an itemized receipt for reimbursement. The Plan will pay benefits based on the amount it would have paid under the Plan at a Participating Pharmacy, less the applicable copayment. Formulary (Preferred) Drugs. The plan includes a formulary option. A formulary is a list of commonly prescribed medications that have been selected for their clinical effectiveness, safety and cost. By asking your doctor to prescribe formulary (plan-preferred) medications, you can help control health care costs while maintaining high-quality care. Non-Formulary (Non-Preferred) Drugs. A listing of brand name and generic prescription drugs that are covered, but are not on the preferred drug list. Express Scripts By Mail Pharmacy. A service where prescription drugs are legally dispensed by mail. Express Scripts By Mail should be used to buy long-term medications for chronic health conditions. Long-term medications are those which are usually taken for 3 months or more. The copayments for medications purchased through the mail pharmacy service are listed in the Pharmacy Copayment Schedule. Pharmacy Copayments - $10/$25/50% 125 Max The Plan provides three (3) different copayment levels for covered prescription drugs. Your copayment will be determined based on: 1of 5
2 Whether the medication is a generic or a brand name; and Whether the medication is a formulary (preferred) or non-formulary (non-preferred) drug. The three copayment levels for the Plan are: Tier 1 Generic (lowest copayment) covered generic drugs on the formulary (preferred) list. Tier 2 Brand Name Formulary (Preferred) (middle copayment) covered brand name drugs on the formulary (preferred) list. Tier 3 Non-Formulary (Non-Preferred) (highest copayment) covered generic and brand name drugs not on the formulary (preferred) list. The Claims Administrator will routinely review the drugs in the tier levels and periodically adjust the status of existing or new drugs. To determine any adjustment in a drug s tier level, contact the Claims Administrator at the number on your ID Card or use the Claims Administrator s website at Scripts.com. Pharmacy Copayment Schedule Pharmacy Copayment Schedule Retail (up to 30-day max) Mail Order (up to 90-day max) Generic drug $10 $25.00 Brand Name Formulary (Preferred) drug $25 $75.00 Non-Formulary (Non-Preferred) drug 50% 50% Coinsurance maximum charge $125 Coinsurance maximum charge $375 Limitations on Quantities Dispensed The Plan will pay for the dispensing of up to a 30-day supply of a covered drug on each occasion when you have a prescription filled or refilled at a participating pharmacy. A copayment amount applies to each fill, for up to a 30-day supply of drugs dispensed, unless otherwise indicated in the Summary Grids. When a prescription is dispensed in a kit or vial, rather than a day supply, a copayment may be applied per kit or vial. To determine the limitations on the number of kits or vials dispensed, or the applicable copayment, contact Express Scripts directly. Express Scripts By Mail Pharmacy Service (Mail Order) The Plan will provide for up to a 90-day supply of a covered drug when a prescription is filled or refilled through the Express Scripts by Mail Pharmacy service. Ask your doctor to prescribe up to a 90-day supply, plus refills for up to 1 year (as appropriate). A prescription must be written with 90-day refills to take advantage of the savings under this program. Prescriptions are filled as written. If a prescription is written for less than the 90-day amount and filled through the mail order service, you will be charged the full mail order copayment. For more information on how to utilize this program, please refer to the materials provided in your Express Scripts packet or contact Express Scripts at or visit the website at Scripts.com. Pharmacy Management Programs Additional programs are in place to assist in managing pharmacy costs while continuing to provide the pharmaceuticals you need. Please read this section carefully. If you have questions about these programs, you may contact Express Scripts to obtain more information. Mandatory Mail Order This program is for employees to obtain long-term medications (taken for 3 months or more) through the Express Scripts By Mail Pharmacy service. Long term medications include, but are not limited to, drugs such as those used to treat high blood 2of 5
3 pressure, high cholesterol or allergies. When you receive a prescription for a medication that will be taken on a long-term basis, you will be mandated to obtain these prescriptions through mail order. You will pay your mail order copayment when you use the service for your long-term drugs. However, if you decide to purchase your long-term drugs at a participating retail pharmacy, you will pay more. Prior to having the long term medication mandated to mail order, the plan allows two (2) retail fills. Please allow 14 days for processing for the first mail order medication. After the initial mail order fill, notification will be sent to the member for subsequent 90 day medication fills. Generic Incentive This program is designed to encourage the use of generic drugs, which usually cost 80-87% less than brand name drugs. When a generic drug is available, and you purchase a brand name drug, you will pay the appropriate brand name copayment plus the difference in cost between the brand name drug and the generic drug. Note: This program will apply even if your doctor requests a brand name prescription. Prior Authorization Some medications are covered by the Healthcare Plan only for certain uses or in certain quantities. For example, a drug may not be covered when it is used for cosmetic purposes. Also, the quantity covered may be limited. In these cases, the pharmacy will let you know if additional information is required for your prescription to be covered. Coverage Authorization Prior authorization for: Androgens & Anabolic Steroids Anti-Narcoleptic Agents (provigil) Appetite & Weight Loss Therapy Erythroid Stimulant Growth Hormones Interferon Alpha Irritable Bowel Syndrome Therapy Misc. Derm. (Tazorac Cream Only) Misc. Derm (Retin-A/co & Tazorac all dose forms) Misc. Pulmonary Agents (Xolair) Multiple Sclerosis Therapy Myeloid Stimulants Smoking Deterrents Step Therapy for: Anti-TNF Agents/Rheumatoid Arthritis Therapy (All Agents) Cancer Therapy (all) (acts like TPA) CNS Stimulants/Strattera/Amphetamines COX 2 Inhibitors (standard) Depression Therapy (Wellbutrin SR and Wellbutrin XL) Leukotriene Antagonists Misc. Dermatologicals (Protopic/Elidel) Pain Management (Actiq, Fentora) Ribavirin Therapy Quantity/Dose Duration for: Anti-Emetics Anti- influenza Erectile Dysfunction Agents (standard) Hypnotic Agents 3of 5
4 Migraine Therapy (Milligram based) Pain Management (Actiq & Fentora) Age Limits Express Scripts will continue the current process of monitoring age limits for certain drugs. You may contact Express Scripts for more information. When Prescription Drug Benefits Are Not Paid The Plan does not cover: 1. Drugs which do not by law require a prescription order from a provider (except injectable insulin); and drugs, insulin, or covered devices for which no valid prescription order is obtained. 2. Devices or durable medical equipment of any type (even though such devices may require a prescription order), such as, but not limited to, therapeutic devices, artificial appliances, or similar devices (except disposable hypodermic needles and syringes for self-administered injections). 3. Administration or injection of any drugs. 4. Vitamins (except those vitamins which by law require a prescription order and for which there is no non-prescription alternative). 5. Drugs dispensed in a physician s office or during confinement while a patient in a hospital, or other acute care institution or facility, including take-home drugs; and drugs dispensed by a nursing home or custodial or chronic care institution or facility. 6. Covered drugs, devices, or other pharmacy services or supplies provided or available in connection with an occupational sickness or an injury sustained in the scope of and in the course of employment whether or not benefits are, or could upon proper claim be, provided under the Workers Compensation Law. 7. Covered drugs, devices, or other pharmacy services or supplies for which benefits are, or could upon proper claim be, provided under any present or future laws enacted by the legislature of any state, or by the Congress of the United States, or the laws, regulations or established procedures of any county or municipality, or any prescription drug which may be properly obtained without charge under local, state, or federal programs, unless such exclusion is expressly prohibited by law; provided, however, that the exclusions of this section shall not be applicable to any coverage held by the participant for prescription drug expenses which is written as a part of or in conjunction with any automobile casualty insurance policy. 8. Any services provided or items furnished for which the pharmacy normally does not charges. 9. Drugs for which the pharmacy s usual and customary charge to the general public is less than or equal to the amount of the appropriate prescription drug copayment amount. 10. Non-systemic contraceptives, devices or implants. 11. Any prescription antiseptic or fluoride mouthwashes, mouth rinses, or topical oral solutions or preparations. 12. Cosmetic drugs used primarily to enhance appearance, including, but not limited to, correction of skin wrinkles and skin aging. 13. Any Retin-A or pharmacologically similar topical drugs for participants age 35 and older, unless medically necessary. 14. Drugs required by law to be labeled: Caution Limited by Federal Law to Investigational Use, or experimental drugs, even though a charge is made for the drugs. 15. Covered drugs dispensed in quantities in excess of the Day Supply amounts stipulated under Limitations on Quantities Dispensed or refills of any prescriptions in excess of the number of refills specified by the physician or by law, or any drugs or medicines dispensed more than one year following the prescription order date. 4of 5
5 16. Legend drugs which are not approved by the U.S. Food and Drug Administration (FDA) for a particular use or purpose or when used for a purpose other than the purpose for which FDA approval is given. 17. Fluids, solutions, nutrients, or medications (including all additives and chemotherapy) used or intended to be used by intravenous or gastrointestinal (internal) infusion or by intravenous injection in the home setting. 18. Drugs prescribed and dispensed for the treatment of obesity or for use in any program of weight reduction, weight loss, or dietary control; except that medically necessary treatment (including prescription drugs) of morbid obesity shall be a specific exception to this exclusion. 19. Drugs used or intended to be used in a manner which would be illegal, unethical, imprudent, abusive, not medically necessary, or otherwise improper. 20. Drugs obtained by unauthorized, fraudulent, abusive, or improper use of the ID Card. 21. Drugs used or intended to be used in the treatment of a condition, sickness, disease, injury, or bodily malfunction which is not covered under the Plan or for which benefits have been exhausted. 22. Rogaine, minoxidil or any other drugs, medications, solutions or preparations used or intended for use in the treatment of hair loss, hair thinning or any related condition, whether to facilitate or promote hair growth, to replace lost hair, or otherwise. 23. Any special services provided by the Pharmacy, including but not limited to counseling and delivery. 24. Smoking cessation products and the treatment of nicotine addiction, unless such products require a prescription order by law. 25. Athletic performance enhancement drugs. 26. Ostomy Supplies. 27. Glucowatch/sensors. 28. Mifeprex. 29. Allergy Sera. 30. Biologicals, Immunization agents or Vaccines. 31. Blood or blood plasma products. 32. Any services or supplies not specifically defined as covered drugs herein. 5of 5
This document contains summary information for your reference. It may not contain all of the priorauthorization requirements and specific restrictions, exclusions and limitations associated with this Prescription
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