Prescription Drug Plan

Transcription

1 Prescription Drug Plan The prescription drug plan helps you pay for prescribed medications using either a retail pharmacy or the mail order program. For More Information Administrative details and procedures for appealing a claim can be found in the Administrative Information section. Highlights Options Cost Per Pay Who Is Covered Coverage Begins Prescription drug benefits are automatically provided when you are enrolled in the medical plan. Paid for by Honda Eligible associates and their eligible dependents First day of the month following your date of hire, if you are eligible for coverage Prescription Drug Plan HAM/EGA/HNA 133 January 1, 2014

2 Highlights About this Benefit Special Features Coverage Ends Administered by Benefits are administered by CVS Caremark, which offers three types of pharmacy services: retail (or pharmacy) for short-term prescriptions mail order for long-term medications and/or specialty medications for chronic or genetic conditions Your prescription drug costs are determined by the type of prescription drugs you receive (generic, non-preferred brand-name or preferred brand-name) and how you have them filled. For maximum benefits: Use your CVS Caremark prescription drug card at network pharmacy for shortterm prescriptions For long-term medications, use mail order program/maintenance Choice Last day of month your Honda employment ends CVS Caremark Table of Contents Who Is Eligible When Coverage Begins How the Prescription Drug Plan Works Your Share of the Cost Covered Expenses Expenses Not Covered by the Plan Claims When Coverage Ends Glossary Prescription Drug Plan HAM/EGA/HNA 134 January 1, 2014

3 Who Is Eligible Eligibility for you and your dependents is defined in the Participating in Health Benefits section. When Coverage Begins When coverage begins is described in the Participating in Health Benefits section. How the Prescription Drug Plan Works Prescription drug benefits are automatically provided when you are enrolled in the medical plan. Benefits are provided by CVS Caremark, which offers three types of pharmacy services: retail (or pharmacy) for short-term prescriptions, and mail order for long-term medications and/or specialty medications for chronic or genetic conditions. Types of Prescription Drugs You pay a copay or coinsurance for each prescription drug you purchase. The amount of the copay or coinsurance depends on how you have the prescription filled and the type of drug: generic, preferred brand or non-preferred brand prescription drugs. There are certain drugs that are not covered under the plan. CVS Caremark s formulary retains comprehensive therapeutic coverage of drug classes with safeguards for members requiring medical necessity exceptions. Honda ensures that you have access to the appropriate drugs needed to stay healthy and have the resources necessary to support their transition to cost-effective formulary alternatives. Please contact CVS Caremark for the current list of exclusions. Keep in mind that if you choose a brand prescription drug when a generic is available, you will pay the appropriate brand drug coinsurance up to the maximum as well as the difference between the cost of the generic and the brand name drug. Generic. Drugs whose active ingredients, safety, quality and strength are the same as their brand-name counterparts. Preferred Brand. Drugs that generally have no generic equivalent. Within a class of drugs, there are often several brand-name drugs protected by separate patents. Each of these is equally effective for treating a particular condition. A list of preferred brand-name drugs, which identifies drug classes that may have generic availability that could save you money, is available from CVS Caremark Customer Care or Non-Preferred Brand. Drugs that have equally effective and less costly generic equivalents and/or have one or more preferred brand options. See the Glossary on page 141 for more information about these types of drugs. Do Not Forget Your CVS Caremark Prescription Drug Card Make sure you use a pharmacy that accepts your CVS Caremark prescription drug card. Simply show your CVS Caremark card to get maximum benefits and you will not have to file a claim. Prescription Drug Plan HAM/EGA/HNA 135 January 1, 2014

4 CVS Caremark Website Remember that the CVS Caremark website is available to you 24 hours a day, 7 days a week for pharmacy information. Simply log in to for a variety of information, including: Prescription drug information Prescription drug costs Information on generic vs. preferred and non-preferred brand-name drugs Paid claims Retail Services When your doctor prescribes medication for an acute (or short-term) condition, use a CVS Caremark participating pharmacy. You will find that most pharmacies in your area accept your CVS Caremark card. Then, simply show your card to the pharmacist and you will pay a copay based on the type of prescription drug you buy, as shown in Your Share of the Cost on page 138. If you fill your prescription at a pharmacy that does not accept Caremark, you will have to file a claim form for reimbursement. You may be reimbursed up to the negotiated cost of the drug minus your applicable copay or coinsurance. You will pay the copay/coinsurance plus any amounts over the negotiated rate for the drug. Mail Order or Maintenance Choice Program You should use the CVS Caremark mail order or Maintenance Choice program for your long-term maintenance prescriptions those needed for an ongoing or chronic condition. This program allows you to receive up to a three-month supply (90 days) either through the mail or at a CVS Caremark retail store for most maintenance medications. To encourage use of the mail order or Maintenance Choice program, you will pay $25 in addition to your regular copay or coinsurance, beginning with the fourth refill of a prescription at a retail pharmacy. (See Your Share of the Cost on page 138 for the copays or coinsurance that applies.) To use the mail order program, get a prescription from your doctor for up to a 90-day supply, plus any appropriate refills. Complete a mail order service form and send it with the original prescription to CVS Caremark. Forms are available from CVS Caremark, Human Resources or Benefits. Payment by check, money order or credit card should be included with your order. Additional features available include automatic refills and automatic renewal. You can sign up for these by logging on to or calling CVS Caremark directly. Important Note! First time mail order users can get started by using the Fast Start program. Simply dial and speak to a CVS Caremark representative who will gather information and contact your physician on your behalf. Additional Options Maintenance Choice. A program is available to you that provides added convenience in filling your maintenance drugs. You may obtain a 90-day prescription at a retail CVS store. Keep in mind that the prescription must be written to dispense in a 90-day supply, plus any appropriate refills. Prescription Drug Plan HAM/EGA/HNA 136 January 1, 2014

5 If you are a first time mail order user, you can get started by using the Fast Start program. You can dial and speak to a CVS Caremark representative who will gather important information and contact your physician to obtain a 90-day prescription on your behalf. Your medication is conveniently and safely shipped to your home within 10 to 14 days. You can also order refills by phone by calling , 24 hours a day. Under Maintenance Choice, you also may obtain a 90-day prescription at a retail CVS Caremark store. Exclusions or Limitations Some medications are not available through the mail order program, including: Medications (e.g., antibiotics) used to treat short-term illnesses Narcotics Drugs that cannot be refilled without a written prescription, etc. Call or contact for more information on exclusions or limits that may apply to mail order drugs. Prior Authorization for Certain Drugs Certain drugs, due to safety, health and cost concerns, require prior authorization by CVS Caremark prior to dispensing. For a list of these drugs, log in to or obtain a list from CVS Caremark (visit or call Customer Care at ). Certain Preventive Medications Covered with No Cost Sharing* Medications including those listed below are covered with no cost to you with a valid prescription. Generic birth control medication and brand-name medications with no generic availability Certain birth control devices, including emergency contraception, injectable, transdermal, and implantable contraception, vaginal rings and barrier methods (such as diaphragms and cervical caps) Certain smoking cessation medications (limited to two cycles annually) Aspirin Fluoride (for children up to age 6) Iron supplementation (for children 6-12 months) Vaccines (currently covered at 100% through Medical plan) * You may contact CVS Caremark for more specifics on these items. Vitamin D Coverage Over the counter Vitamin D is covered at 100% for men and women who are age 65 and older. No prior authorization is required for dosages from 600 IU 800 IU. Specialty Pharmacy Services The specialty pharmacy services are available for chronic and genetic disorders. This service offers convenient delivery of your specialty medicines and free ancillary supplies. It also offers personalized services and education support for your specific therapy. Prescription Drug Plan HAM/EGA/HNA 137 January 1, 2014

6 CVS Caremark assigns a team of professionals to help you and your family successfully manage chronic and genetic conditions. This service includes 24-hour access to a clinical pharmacist for consultation. Services are available for allergic asthma, Crohn s disease, enzyme replacement, Gaucher s disease, growth hormone deficiency, hemophilia, hepatitis C, immune disorders, multiple sclerosis, psoriasis, pulmonary hypertension, rheumatoid arthritis, Respiratory Syncytial Virus (RSV) prevention and other conditions. You pay one copay when you obtain up to a 30-day supply of drugs through the specialty pharmacy services; you pay two copays for a 90-day (three-month) supply. To inquire about or begin services with CVS Caremark Specialty Pharmacy Services, please call or have your healthcare provider call CaremarkConnect at You may also begin the enrollment process online. Once you fill out the requested information, a CVS Caremark specialist will contact you. Regardless of how you begin the process, CVS Caremark s specialists will work with you and your provider to confirm coverage for your treatment and will conduct a full benefits investigation for the medicines you may need. How CVS Caremark Works with You One of the ways CVS Caremark ensures your safety is through a review process that evaluates prescriptions that are filled through our mail order program or at a participating local retail pharmacy. In some instances, a CVS Caremark pharmacist may consult with your doctor by telephone or fax to discuss a current prescription. Your doctor may agree to change the medicine, adjust the number of doses or alter the length of time you need to take the medicine. Please remember that your doctor is the final decision-maker regarding any changes in your course of therapy. CVS Caremark will not change a prescription without full consent of your prescribing doctor, either directly or through an authorized agent. If the pharmacist and the doctor agree that an alternate medicine is not appropriate for you, the prescription will be filled as originally written. Your Share of the Cost Your prescription drug copays or coinsurance are determined by the type of prescription drugs you receive (e.g., generic versus non-preferred brand-name). In addition, your share of the cost also varies depending on how you have your prescriptions filled and whether you are enrolled in the Active or the Passive healthcare plan, as shown below. If you refill a 30-day prescription at a retail pharmacy for the fourth time, you will have to pay $25 in addition to your regular copay or coinsurance. Prescription Drug Active Healthcare Plan Passive Healthcare Plan Retail copays/coinsurance (up to 30-day supply) Generic $5 $10 Preferred brand-name 25% ($10 minimum; $50 maximum 35% ($25 minimum; $60 Non-preferred brand-name 25% ($30 minimum; $75 35% ($50 minimum; $85 Mail order/maintenance Choice copays/coinsurance (up to 90-day supply) Generic $10 $20 Prescription Drug Plan HAM/EGA/HNA 138 January 1, 2014

7 Prescription Drug Active Healthcare Plan Passive Healthcare Plan Preferred brand-name 25% ($20 minimum; $100 35% ($50 minimum; $120 Non-preferred brand-name 25% ($60 minimum; $150 35% ($100 minimum; $160 Preferred and Non-Preferred Brand Drug Minimums and Maximums If the percentage cost of your drug is less than the minimum shown above, you will pay the minimum fixed dollar copay shown above. If the percentage cost of your drug is higher than the maximum shown above, you only pay the maximum fixed dollar copay shown. Covered Expenses The following are covered under the prescription drug plan: Drugs and medicines which can be legally obtained only by the written prescription of a physician or other legal prescriber and are approved by the U.S. Food and Drug Administration for general human use Diabetic supplies including: insulin prescribed in writing by a physician or other legal prescriber disposable blood/urine glucose/acetone testing agents and lancets Contraceptives for birth control. Please note, certain contraceptives are only packaged in a 90-day supply; because of this, the mail order or Maintenance Choice program must be used to fill these prescriptions Blood Glucose Meter Program Plan participants who are diagnosed with diabetes and test their blood sugar may receive a complimentary blood glucose meter kit by calling the CVS Caremark Pharmacy Resource Center (PRC) at The PRC s hours of operation are 9 a.m. to 7 p.m. EST, Monday through Friday. To receive a complimentary meter, you must meet the following criteria: You must be diagnosed with diabetes, or required by the doctor to test your blood sugar You must agree to order a minimum of a 90-day supply of test strips through the mail order program to accompany the meter you choose Complimentary blood glucose meters are available once every three years, provided you qualify and continue to meet the criteria listed above. There are five preferred blood glucose meters to choose from. When you call to request a meter kit, you will be transferred to the PRC Meter Team. The Meter Team staff will describe the five preferred meters and help you choose one. They will also contact your physician to obtain the prescription for the test strips (and lancets if needed). The meter kits come directly from the manufacturer to your home, and the prescription for the test strips and lancets will come from the mail order pharmacy. Note: The Meter Team can only address issues regarding the ordering of meters, test strips and lancets, not other diabetic supplies. Prescription Drug Plan HAM/EGA/HNA 139 January 1, 2014

8 Expenses Not Covered by the Plan The plan does not cover: Drugs dispensed by a physician s office Charges for administering any drug or insulin Allergy serums Immunization agents, biological serum and blood/blood plasma Therapeutic devices or appliances, including support garments and other non-medicinal substances Over-the-counter drugs (except for certain preventive care drugs when you have a prescription) Compound lotion form of minoxidil when prescribed for cosmetic purposes (that is, to alter appearance without restoring or improving impaired physical function) Experimental drugs and those labeled as limited by federal law to investigational use Any prescription refilled beyond the number allowed by the physician or refills dispensed later than one year after the date your physician wrote the prescription. You will need to get the prescription filled for the first time generally within six months of the date the prescription was written. (Note: This may vary for controlled substances) Medication taken or administered while in a licensed hospital, rest home, sanitarium, extended care facility, convalescent hospital, nursing home or similar facility with an operating pharmacy Prescription drugs which are available to you without charge under Workers Compensation laws Weight loss drugs Certain sleep aids Erectile dysfunction aids or medications Claims There are no claims to file if you: Use your CVS Caremark drug card at a participating pharmacy Use the mail order program for long-term/specialty prescriptions If you purchase medications at a pharmacy that does not accept your CVS Caremark card, you pay the full cost of the prescription. Then, you need to file a CVS Caremark reimbursement claim form. The back of the form tells you how to submit the claim. You are responsible for the applicable coinsurance/copayment plus any difference if the original cost exceeds the contracted cost. You can get a form by calling CVS Caremark Customer Care at or by visiting Prescription Drug Plan HAM/EGA/HNA 140 January 1, 2014

9 When Coverage Ends When coverage ends is described in the Participating in Health Benefits section. In certain cases, you or your dependent may continue prescription drug coverage for a limited time by paying the full cost. See the COBRA section for more information. Glossary The following definitions are provided to help you understand your prescription drug coverage. Brand-Name Drug A prescription drug that trademark registration protects. Generic Drug A drug whose active ingredients, safety, quality and strength are the same as its brand-name counterpart. Non-Preferred Brand Drugs that have equally effective and less costly generic equivalents and/or have one or more preferred-brand options. Preferred Brand Drugs that generally have no generic equivalent. Within a class of drugs, there are often several brand-name drugs protected by separate patents. Each of these is equally effective for treating a particular condition. Preferred Drug List A preferred drug list is a list of recommended brand-name prescription drugs reviewed and updated every three months by a CVS Caremark committee of independent physicians and pharmacists. A medication becomes a preferred-brand drug based on safety, effectiveness and then cost. The preferred list identifies drug classes that may have generic availability that could save you money. Prescription Drug Plan HAM/EGA/HNA 141 January 1, 2014

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