The Plan pays, subject to any limitations specified under Your Benefits, the cost incurred for outpatient prescription drugs that are obtained from a participating pharmacy. Express Scripts is the pharmacy benefit manager for your prescription drugs. You must present your Express Scripts or Medco ID card and make the copayment shown in the Benefits summary for each prescription at the time the prescription is dispensed.
The Plan covers the costs of prescription drugs, in excess of the copayment, that are:
- Medically necessary for the care and treatment of an illness or injury, as determined by Express Scripts;
- Prescribed in writing by a physician who is licensed to prescribe federal legend prescription drugs or medicines, and
- Not listed under Prescription Drug Exclusions and Limitations, below.
Non-emergency prescriptions must be filled at a participating pharmacy. Generic drugs may be substituted for brand-name products where permitted by law.
Coverage is based upon Express Scripts’ formulary. A formulary is a list of commonly prescribed medications within particular therapeutic categories. The drugs on the list have been selected based on their effectiveness and cost. To be included in the formulary list, a drug must meet rigorous standards of approval by the Express Scripts Pharmacy and Therapeutic Committee — a group of nationally recognized medical professionals. The formulary includes both brand-name and generic drugs and is designed to provide access to quality, affordable outpatient prescription drug benefits. You can reduce your copayment by using a covered generic or brand-name drug that appears on the formulary. Your copayment will be highest if your physician prescribes a covered drug that does not appear on the formulary. It is always up to your doctor to decide which medications to prescribe. If you have questions about the Express Scripts formulary, you should contact Express Scripts directly.
Long-term or maintenance medications
A long-term or maintenance medication is a drug you take for an extended period of time, such as for the ongoing treatment of diabetes, arthritis, a heart condition, or blood pressure. After the third short-term fill of a maintenance medication, subsequent refills must be purchased as a 90-day supply at a Smart90 retail pharmacy (Walgreens, CVS) or Express Scripts home delivery pharmacy. If you continue to purchase short-term fills of a long-term or maintenance medication after the third fill, you will be responsible for 100% of the cost.
You may order refills by calling Express Scripts or sending in the refill label provided with your previous order. You may also order refills through Express Scripts’ website. You should order a refill about three weeks before your current supply will be exhausted, but remember that you must have generally used 75% of the previous prescription based on the prescribed dosage. During natural disasters, you may be able to replace lost or damaged medications without having used 75% of the previous prescription.
Specialty medications, including injectables and infusions for rheumatoid arthritis and other inflammatory conditions, require special handling and may be administered in a hospital, clinic, doctor’s office, or in your home. Some specialty medications, like most oncology drugs administered in a hospital setting, are covered under the medical benefit administered by Aetna. Other specialty medications are covered under the prescription drug program administered by Express Scripts. If you have questions about starting a specialty medication, call Aetna member services and ask to speak to a Health Advocate nurse.
Specialty medications administered by Express Scripts are filled through their specialty pharmacy, Accredo, and can be delivered to hospitals, clinics, doctor’s offices, or to a home health care provider. Although the percentage copayments and maximum per prescription for specialty drugs are generally the same as for brand name drugs, higher copayments may be charged for certain preferred specialty medications determined to be non-essential health benefits. However, many of these medications may be available at no cost when purchased through the Plan’s copay assistance program. If the specialty medication being purchased qualifies for copay assistance, you will be contacted by a pharmacist from the Accredo specialty pharmacy and asked to enroll in the program. If you choose not to enroll in the program, you will be responsible for the higher copayment.
You may not have access to a participating pharmacy in an emergency or urgent care situation, or if you are traveling outside of the Plan’s service area. If you must have a prescription filled in such situations, the Plan will reimburse you as follows:
- Non-Participating Pharmacy – You must pay the pharmacy directly for the full cost of the prescription and you will be responsible for submitting a request for reimbursement in writing to the pharmacy benefit manager with a receipt for the cost of the prescription. The pharmacy benefit manager will directly reimburse the Member 100% of the prescription, less the applicable copay. Coverage for items obtained from non-participating pharmacies is limited to items obtained in connection with covered Emergency and Out-of-Area Urgent Care services. Contact Express Scripts Member Services for more information.
- Participating Pharmacy – When you obtain an emergency or urgent care prescription at a participating pharmacy (including an out-of-area participating pharmacy), you must pay the applicable copay. The pharmacy benefit manager will not reimburse claims submitted as a direct reimbursement request from a Member for a prescription purchased at a participating retail pharmacy except upon professional review and approval by the pharmacy benefit manager.
The Plan covers the following:
- Outpatient prescription drugs when prescribed by a provider who is licensed to prescribe federal legend drugs or medicines, subject to the terms, limitations and exclusions described in this booklet.
- FDA-approved prescription drugs when the off-label use of the drug has not been approved by the FDA to treat the condition in question, provided that:
- the drug is recognized for treatment of the condition in one of the standard reference compendia (the United States Pharmacopoeia Drug Information, the American Medical Association Drug Evaluations, or the American Hospital Formulary Service Drug Information), or
- the safety and effectiveness of use for the condition has been adequately demonstrated by at least one study published in a nationally recognized peer reviewed journal.
- Diabetic supplies as follows:
- diabetic needles and syringes
- alcohol swabs
- test strips for glucose monitoring and/or visual reading
- diabetic test agents
- lancets (and lancing devices)
- prescriptive and nonprescriptive oral agents for controlling blood sugar levels
- glucagon emergency kits
- Smoking Cessation aids and drugs prescribed by a physician.
- Oral and implantable contraceptive drugs and contraceptive devices.
- Injectable contraceptives (Depo-Provera).
- Growth hormone therapy, when pre-certified by Express Scripts
Prescription drug exclusions and limitations
Prescription drug exclusions
The following services and supplies are not covered by the Plan, and a medical exception is not available for coverage:
- Any drug that does not, by federal or state law, require a prescription order (such as an over-the- counter drug), even when a prescription is written.
- Any drug that is not medically necessary.
- Charges for the administration or injection of a prescription drug or insulin.
- Cosmetics and any drugs used for cosmetic purposes or to promote hair growth, including (but not limited to) health and beauty aids.
- Any prescription for which the actual charge to you is less than the copayment.
- Any prescription for which no charge is made to you.
- Insulin pumps or tubing for insulin pumps.
- Medication which is to be taken by you or administered to you, in whole or part, while you are a patient in a licensed hospital or similar facility.
- Take-home prescriptions dispensed from a hospital pharmacy upon discharge from the hospital, unless the hospital pharmacy is a participating retail pharmacy.
- Any medication that is consumed or administered at the place where it is dispensed.
- Immunization or immunological agents, including, but not limited to:
- biological sera.
- blood, blood plasma or other blood products administered on an outpatient basis.
- allergy sera and testing materials.
- Drugs used for the purpose of weight reduction, including the treatment of obesity.
- Any prescription refilled in excess of the number specified by the physician, or any refill dispensed after one year from the physician’s original order.
- Drugs labeled Caution - Limited by Federal Law to Investigational Use and experimental drugs.
- Drugs prescribed for uses other than the uses approved by the FDA under the Food, Drug and Cosmetic Law and regulations.
- Medical supplies, devices and equipment, and non-medical supplies and substances, regardless of their intended use.
- Prescription drugs purchased prior to the effective date, or after the termination date, of coverage under this Plan.
- Replacement of lost or stolen prescriptions.
- Performance and athletic performance lifestyle-enhancement drugs and supplies.
- Smoking-cessation aids or drugs unless prescribed by a physician.
- Test agents and devices, except diabetic test strips.
- Needles and syringes, except diabetic needles and syringes.
- Any drug or device that terminates a pregnancy.
- Prophylactic drugs for travel.
- Nutritional Supplements.
- Medication packaged in unit dose form (except those approved by payment by Express Scripts).
Prescription drug limitations
The following limitations apply to the prescription drug coverage:
- A participating retail or home delivery pharmacy may refuse to fill a prescription order or refill when, in the professional judgment of the pharmacist, the prescription should not be filled.
- Prescriptions may be filled only at a participating retail or home delivery pharmacy, except in the event of emergency or urgent care. Plan participants will not be reimbursed for out-of-pocket prescription purchases from a non-participating pharmacy in non-emergency, non-urgent care situations.
- Plan participants must present their ID cards at the time each prescription is filled to verify coverage. If you do not present your ID card, your purchase may not be covered by the Plan, except in emergency and urgent care situations, and you may be required to pay the entire cost of the prescription.
- The Plan is not responsible for the cost of any prescription drug for which the actual charge to the plan participant is less than the required copayment or for any drug for which no charge is made to the recipient.
- Plan participants will be charged the non-formulary prescription drugs copayment for prescription drugs covered on an exception basis.
- For maintenance medications (those taken on a regular basis to treat ongoing conditions like allergies, asthma, diabetes, heart conditions, etc.), the Plan will provide coverage for three short-term fills at a retail pharmacy; for subsequent short-term fills the participant will be responsible for 100% of the cost. Any long-term refill that is submitted to a Smart90 retail pharmacy (Walgreens, CVS) or the Express Scripts home delivery pharmacy will be subject to the long-term pharmacy copayments.
- When a clinically equivalent generic is available, and a brand name drug is purchased, the copayment will be equal to the generic copayment amount plus the full difference in the cost of the brand name drug and the generic. The difference in cost will not count toward the annual out-of-pocket maximum for prescription drugs.
- Although the percentage copayments and maximum per prescription for specialty drugs are generally the same as for brand name drugs, higher copayments may be charged for certain preferred specialty medications determined to be non-essential health benefits. However, many of these medications may be available at no cost when purchased through the Plan’s copay assistance program. If the specialty medication being purchased qualifies for copay assistance, you will be contacted by a pharmacist from the Accredo specialty pharmacy and asked to enroll in the program. If you choose not to enroll in the program, you will be responsible for the higher copayment.
Advanced Utilization Management (AUM)
In some cases, you may be required to try one or more specified drugs to treat a particular medical condition before the Plan will cover another (usually more expensive) drug. Prior authorization and preferred drug step therapy rules are designed to encourage the use of effective, lower-cost drugs.
As part of Express Scripts’ Advanced Utilization Management (AUM) program, certain drugs will not be covered unless pre-certified by Express Scripts, based on medical evidence submitted by your physician. In addition, some therapies will be monitored for appropriate pharmacogenomic parameters, and oral oncology medications will be limited to ensure appropriate use. Please visit www.express-scripts.com to obtain more information about your medications and if they require a coverage review. If you have a question regarding a drug on the AUM program list, contact Express Scripts at the number listed in the Information Sources section of this SPD.
Preferred drug step therapy rules
Preferred drug step therapy rules are used for certain therapeutic classes of drugs, to encourage the use of effective, lower-cost drugs by initially excluding some targeted medications from coverage, unless prior authorization is provided by Express Scripts. Therapeutic classes include: proton pump inhibitors, sleep agents, depression, osteoporosis, respiratory, cardiovascular, triptans, glaucoma, diabetes, respiratory allergy/asthma, anti-inflammatory and rheumatoid arthritis, growth hormone, stimulants for Attention Deficit Hyperactivity Disorder (ADHD), prostate therapy drugs, topical steroids, and stroke prevention. Non-targeted drugs will be covered without such authorization and will continue to be dispensed with no further action by either you or the prescribing physician. If you have a question regarding a drug in any of these therapeutic classes, contact Express Scripts to determine whether your drug is covered. You will be notified directly by Express Scripts if you are affected by these rules.
Prior authorization rules
Prior authorization rules apply to certain therapeutic classes of drugs; therapies in this section will be monitored for appropriate use, including pharmacogenomics parameters in some cases. These classes include miscellaneous immunological agents, central nervous system/miscellaneous neurological therapy, biotechnology/adjunctive cancer therapy, central nervous system/headache therapy, central nervous system/analgesics, neurology/miscellaneous psychotherapeutic agents, and miscellaneous pulmonary agents. In addition, anabolic steroids, high cost antibiotics, anti-emetics, antivirals, narcotics, acne dermatological and topical pain medications may trigger a prior authorization. Oral oncology medications will also be limited to ensure appropriate use. Certain drugs within each classes as determined by Express Scripts will only be covered to the extent they are authorized by Express Scripts. If you have a question regarding coverage for a drug in any of these therapeutic classes, contact Express Scripts. You will be notified directly by Express Scripts if you are affected by these rules.
Express Scripts’ split fill program applies to certain select specialty conditions where participants often stop or change therapy early in treatment due to side effects or their ability to tolerate treatment. This program will provide smaller initial fills (15-day supply) and clinical support to participants as they begin their therapy. Coinsurance and the per prescription maximum will be applied on a prorated basis so that the participant will not be disadvantaged financially. This program is designed to help manage side-effects, eliminate wasted medications and manage specialty drug costs.