Prescription Drug Benefits
Participating pharmacies (“Participating Pharmacies”) have contracted with the Plan to charge Participants reduced fees for covered Drugs. Express Scripts is the administrator of the prescription drug plan.Participants will be issued an identification card to use at the pharmacy at time of purchase. Participants will be held fully responsible for the consequences of any pharmacy identification card after termination of coverage. No reimbursement will be made when a Drug is purchased from a non- Participating Pharmacy or when the identification card is not used.
The Mail Order Option is available for maintenance medications (those that are taken for long periods of time, such as Drugs sometimes prescribed for heart Disease, high blood pressure, asthma, etc.). Because of the volume buying, Express Scripts, the mail order pharmacy, is able to offer Participants significant savings on their prescriptions.
The Copayment is applied to each charge and is shown on the Summary of Benefits, above. The Copayment amount applies toward the medical plan out-of-pocket maximum.
The following are covered under the Plan:
Drugs that help manage the severity and frequency of acne outbreaks that cannot be purchased over-the-counter.
Bee Sting Kits
Charges for EPI PEN and Ana Kit.
All compounded prescriptions containing at least one prescription ingredient
in a therapeutic quantity.
All Food and Drug Administration (FDA)-approved contraceptives Drugs, in accordance with the Health Resources and Services Administration (HRSA) guidelines.
Insulins, insulin syringes and needles, diabetic supplies – legend, diabetic supplies – over the counter, and glucose test strips, when prescribed by a Physician.
Drug Efficacy Study Implementation (DESI) Drugs
Charges for DESI Drugs.
Charges for Imitrex injections (migraine auto-injector).
Immunization agents or biological sera.
Charges for immunologicals (vaccines).
- Class V Drugs
- Diabetic Supplies
- Legend Drugs with over the counter equivalents
- Pre natal vitamins
Medical Devices and Supplies
Charges for legend and over the counter medical devices and supplies.
Required by Law
All Drugs prescribed by a Physician that require a prescription either by Federal or State
law, except injectables (other than insulin) and the Drugs excluded below.
A charge for Drugs or aids for smoking cessation, including, but not limited to, nicotine gum and smoking cessation patches, to the extent required by the Affordable Care Act (ACA).
The benefits set forth in this section will be limited to:
- With respect to the Pharmacy Option, any one prescription is limited to a 30 day supply.
- With respect to the Mail Order Option, any one prescription is limited to a 90 day supply.
- With respect to the Specialty Drug Option, any one prescription is limited to a 30 day supply.
- Refills only up to the number of times specified by a Physician.
- Refills up to one year from the date of order by a Physician.
In addition to the General Limitations and Exclusions section, the following are not covered by the Plan:
Any charge for the administration of a covered Drug.
Charges for allergy sera.
Anorexiants (weight loss Drugs).
Drugs intended to affect the structure or function of the skin that cannot be purchased over-the-counter.
Blood and Blood Plasma
Charges for blood and blood plasma.
Consumed Where Dispensed
Any Drug or medicine that is consumed or administered at the place where
it is dispensed.
Devices of any type, even though such devices may require a prescription, including, but not limited to, therapeutic devices, artificial appliances, braces, support garments or any similar device.
Experimental Drugs and medicines, even though a charge is made to the Participant. Fertility Agents. Charges for fertility agents.
Charges for growth hormones.
A charge for impotency medication, including Viagra.
A charge for injectables.
A Drug or medicine that is to be taken by a Participant, in whole or in part, while confined in an Institution, including any Institution that has a facility for dispensing Drugs and medicines on its premises.
Investigational Use Drugs
A Drug or medicine labeled “Caution – limited by Federal law to Investigational use”.
A charge for drugs which may be properly received without charge under local, State or Federal programs.
Charges for non-insulin syringes and needles.
Non-Prescription Drug or Medicine
A drug or medicine that can legally be bought without a prescription,
except for injectable insulin.
Charges for over-the-counter drugs, except to the extent required by the Affordable Care Act:
- Medical Devices and Supplies
- Pre-natal vitamins
Charges for Rogaine (topical minoxidil). Steroids. Anabolic steroids.
Vitamins, except pre-natal vitamins.