The eligibility and enrollment rules for the U

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Retiree Health Care SPD Effective January 1, 2012 Formulary Drugs The formulary is a list of commonly prescribed brand-name and generic drugs Medco has designated as “preferred" based on the drug’s clinical effectiveness and opportunities to help contain costs. You will usually receive the highest level of coverage when you use formulary drugs. For these plans, the formulary used includes generics along with approximately one or more brand-name drugs in a therapeutic category. Formulary Status: Generic = lowest cost drugs to U.S. Bank and retirees (generics) Preferred = Moderate cost drugs to U.S. Bank and retirees (brand-name drugs on the formulary drug list) Non-Preferred = Highest cost drugs to U.S. Bank and retirees (brand-name drugs NOT on the formulary drug list). Some drugs may be grouped together as Non-Preferred. Examples include “preferred” Proton Pump Inhibitors (PPI) = Heartburn/acid reflux medications such as Nexium and all compounded medications. At times you may also see drugs referred to as Tiers. A tier is typically the copayment/coinsurance level assigned to that drug as follows: Tier 1 = usually generic drugs Tier 2 = usually formulary (preferred) drugs Tier 3* = usually non-preferred drugs Tier 4* = some drug classes may be grouped into Tier 4 which include both preferred and nonpreferred drugs (for example, PPI medications and compounded medications). *Tier 3 and Tier 4 are both considered the highest copayment/coinsurance level. Once enrolled, you may view the formulary (preferred) status of a medication at www.medco.com. Sometimes your doctor may prescribe a non-preferred medication for which either a formulary (preferred) brand-name or generic alternative drug is available. If your doctor specifies that a prescription be “dispensed as written” or “DAW”, the pharmacist may ask your doctor whether a generic or an alternative formulary (preferred) drug might be appropriate for you. Only if your doctor agrees, your prescription will be filled with the substituted or alternative drug. A confirmation will be sent to you and your doctor explaining the change. Ask your doctor if you have questions about a change in prescription. Your doctor always makes the final decision on your medication, and you can always choose to keep the original prescription. Pharmacies will dispense only the medication authorized by your doctor. NOTE: The Medco Pharmacy (Medco’s mail order service) will automatically dispense a generic, unless your doctor indicates “DAW” or “dispense as written” on the prescription. Other substitutions may be made by the pharmacist after consulting with your doctor. Regardless of what your doctor prescribes, you are responsible for the applicable copayment/coinsurance based on the drug you receive. When applicable, if a brand-name drug is dispensed and a generic drug is available, you will pay the brand coinsurance plus the cost difference between the brandname and the generic per covered prescription. Please remember that the price of prescription drugs can fluctuate, which may affect your cost for the medication. In addition, drugs can be added to or removed from the formulary throughout 68
Retiree Health Care SPD Effective January 1, 2012 the year. Note: PPI medications such as Nexium and compounded medications will be covered at the highest brand-name drug coinsurance level of 45%. In addition, applicable coinsurance minimum and maximums will apply. To verify whether your drug is on the formulary list, or if there are any additional pharmacy benefit limitations, you may also call Medco at 1-800-864- 1404. Diabetic Supply Exception If you are enrolled in the Early Retiree Medical Option – under this exception, diabetic supplies such as syringes, test strips, and lancets, are covered at 100% once your combined pharmacy/medical deductible has been met when received at a participating retail pharmacy or mail order using the Medco Pharmacy*. This exception applies to only diabetic supplies, not diabetic medications (oral or injectable) such as insulin. If you are enrolled in the Comprehensive, Medica or UnitedHealthcare options - under this exception, diabetic supplies such as syringes, test strips, and lancets, are covered at 100%, no deductible when received at a participating Retail Pharmacy or mail order using the Medco Pharmacy*. This exception applies to only diabetic supplies, not diabetic medications (oral or injectable) such as insulin. *Diabetic supplies are considered a maintenance medication. Therefore, the “Mail Order Maintenance Drug Provision” applies for all options. See the “Mail Order Maintenance Drug Provision” section in this SPD for more information. Mail Order Maintenance Drug Provision Maintenance medications are those prescription drugs (including injectable and specialty injectable drugs) taken on a long-term basis – such as those used to treat allergies, diabetes, high cholesterol or high blood pressure. In addition, medications you take continually, such as oral contraceptives are considered maintenance medications as well as diabetic supplies such as syringes, test strips and lancets. Under this provision there is a maximum retail refill allowance (RRA). This means you may fill your maintenance medication prescription at your Retail Pharmacy for a one-month supply, followed by one refill at your Retail Pharmacy. To continue to receive pharmacy benefit coverage after your first two fills (does not reset per calendar year), you need to order your next refill through the Medco Pharmacy (Medco’s mail order service). If you fill your maintenance medication at your Retail Pharmacy after your first two fills, you will receive no coverage and you will be responsible for the full cost of the prescription. Note: The two-fill limit does not reset per plan year, prior applicable refills are considered*. *At times, counting two fills can be challenging due to the vast number of medications, dosages, strengths, etc. In addition, intermittent use or fills of a maintenance medication may impact the fill-counting logic. If you have any questions about your medications or to determine which medications are subject to a retail refill limit, contact Medco at 800-864-1404. To order maintenance medications send your prescription to the Medco Pharmacy (Medco’s mail order service) and have the medication delivered conveniently right to you. 69
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The eligibility and enrollment rules for the U

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