The eligibility and enrollment rules for the U

More documents

Recommendations

Info

Retiree Health Care SPD Effective January 1, 2012 when a medication you are taking qualifies for the step therapy program. In some situations, the step therapy medication may be covered automatically if your medication history shows you have tried a formulary (preferred) medication some time in the past. If not automatically covered, a toll-free number is provided via the online messaging, in which your pharmacist (or you) can initiate the review process necessary to allow coverage for your medication identified as part of the step therapy program. In some situations your doctor may decide to change your prescription to the less costly formulary (preferred) medication after discussing options with the Medco step therapy area. Some conditions/medications that require step therapy include pain/arthritis, high blood pressure, osteoporosis, hypnotic sleep medications, depression, cholesterol lowering agents, rheumatoid arthritis, psoriasis, cancer specialty medications, narcotic pain medications, intranasal steroids, migraine headache – triptan medications, sensipar, pulmonary arterial hypertension agents, gastrointestinal acid-peptic disorders, Gaucher’s agents and Gout medications. This is not intended to be an exhaustive list and is subject to change without notice. In addition, refer to the “Prior Authorization for Pharmacy Coverage” section in this SPD for additional information. Frequently Asked Questions About Step Therapy Why should use of second-line drugs be limited? Second-line drugs may have more side effects, be more difficult to take, and/or be more expensive than their first-line alternatives. Can I get coverage for a second-line drug even if I have not tried a first-line drug? In some cases, the answer is yes. Exception processes are available for the rare cases in which no first-line drug is appropriate. If you meet certain medical criteria, you may be able to get coverage through the prior authorization process. Refer to the “Prior Authorization for Pharmacy Coverage” section in this SPD for additional information. Does a change to a first-line drug have to be approved by my doctor? Yes, because it involves a change to the drug being dispensed. No prescriptions will automatically be changed based on the step therapy program. If my prescription is changed, will my copayment/coinsurance also change? Your copayment/coinsurance may be lower. In many cases, the first-line drug is a generic and therefore has a lower copayment/coinsurance than the second-line drug, which is typically a brand-name product. How are first- and second-line drugs chosen? Medco’s independent Pharmacy and Therapeutics Committee of pharmacists and doctors select the first- and second-line drugs after careful review of medical literature, manufacturer product information, and consultation with medical professionals. These steps are taken to make sure that the protocols reflect the most current and appropriate drug therapy recommendations. If you have specific questions about step therapy and how it may affect your prescription drugs, call Medco at 1-800-864-1404. You also may visit www.medco.com for general and personalized prescription drug information. 78
Retiree Health Care SPD Effective January 1, 2012 Additional Pharmacy Benefit Limitations There are additional criteria, such as safety and cost, that are considered in determining which drugs are covered under the pharmacy benefit and in what amount or dosage. Examples of these limitations include: • Brand-name and generic drugs – The brand name of a drug is the product name under which the drug is advertised and sold. Many brand-name medications have become well known through advertising. Generic medications are sold under generic, often unfamiliar, names. The U.S. Food and Drug Administration (FDA) requires FDA-approved generics to have the same active ingredients and are subject to the same rigid FDA standards for quality, strength and purity as their brand-name counterparts. You must use generic drugs if they are available for your condition in order to receive the highest level of benefits. If a brand-name drug is dispensed when a generic equivalent is available – whether requested by you or your doctor – you will pay the cost difference between the brand-name and generic medications, plus your brand-name coinsurance. • Quantity limits – In most cases, when you fill a prescription you will receive the prescribed amount, up to a 31-day supply through the Retail Pharmacy or up to a 90-day supply through the Medco Pharmacy (Medco’s mail order service). Certain drugs are limited, however, to a set quantity – regardless of what your doctor prescribes. The allowed amount is based on FDA-approved dosing guidelines and medical literature or limited as per individual state regulations. Examples of drugs with quantity limits are medications for high blood pressure, cholesterol, diabetes, asthma, osteoporosis, depression, pain, ulcers, allergies, gout, psoriasis, Alzheimers and Multiple Sclerosis, Parkinson’s, Rheumatoid Arthritis, migraine products (e.g., Imitrex), hypnotic sleep medications, antifungal agents, TOBI, Acthar Gel, erectile dysfunction agents (e.g., Viagra), pulmonary arterial hypertension agents, cancer medications, antivirals, interferons, anti-emetics, estrogens, and RSV agents. However, these are only examples and not an exhaustive list. • Lifetime maximums – Certain drugs are limited to a set lifetime maximum – regardless of what your doctor prescribes. Examples of drugs with lifetime maximum limits are prescription medications for the treatment of infertility. The lifetime maximum may be reached by intermittent or continuous drug therapy. Once satisfied, no further benefits will be payable. For more information refer to the “Infertility Coverage Maximum” section in this SPD. • Proton Pump Inhibitors (PPI) – Branded PPI medications (heartburn/acid reflux medications) such as Nexium will be covered at the highest brand-name drug coinsurance level of 45%. In addition, applicable coinsurance minimum and maximums will apply. • Compounded Medications – Compounded medications (when covered) will be paid at the highest coinsurance level of 45%. In addition, applicable coinsurance minimum and maximums will apply. Please contact Medco at 1-800-864-1404 or visit www.medco.com if you have questions about coverage and/or limits for a specific prescription drug. Infertility Coverage Maximum A $7,500 lifetime maximum per family (not per person) applies to all infertility prescription drugs. A separate $2,500 lifetime maximum per family (not per person) applies to all infertility services, including medical and surgical treatment. Refer to “Infertility Treatment” under “What the Options Cover” section in this SPD for more information. 79
Page 1 and 2:
Retiree Health Care SPD Effective J
Page 3 and 4:
Page 5 and 6:
Page 7 and 8:
Page 9 and 10:
Page 11 and 12:
Page 13 and 14:
Page 15 and 16:
Page 17 and 18:
Page 19 and 20:
Page 21 and 22:
Page 23 and 24:
Page 25 and 26:
Page 27 and 28: Retiree Health Care SPD Effective J
Page 77: Retiree Health Care SPD Effective J
Page 129 and 130:
Page 131 and 132:
Page 133 and 134:
Page 135 and 136:
Page 137 and 138:
Page 139 and 140:
Page 141 and 142:
Page 143 and 144:
Page 145 and 146:
Page 147 and 148:
Page 149 and 150:
Page 151 and 152:
Page 153 and 154:
Page 155 and 156:
Page 157 and 158:
Page 159 and 160:
Page 161 and 162:
Page 163 and 164:
Page 165 and 166:
Page 167 and 168:
Page 169 and 170:
Page 171 and 172:
show all

The eligibility and enrollment rules for the U

Create successful ePaper yourself

Delete template?

Save as template?