Medco prescription plan summary 2012

PLAN IS EFFECTIVE AS OF JANUARY 1, 2012
There are two prescription drug benefit plans: the Standard Plan and the Premium Plan. Your prescription plan is determinedby your diocese or group and was noted on your personalized open enrollment form. If you are in the Premium Plan, it is alsonoted on your ID card. The High Deductible Health Plan has its own prescription drug plan.
Standard
RETAIL PRESCRIPTION DRUGS
MAIL-ORDER PRESCRIPTION DRUGS
Annual Prescription
Deductible
Tier 1: Generic
Tier 2: Formulary Brand-Name
Tier 3: Non-Formulary Brand-Name and
Brand Non-Sedating Antihistamines
Dispensing Limits Per
Copayment
RETAIL PRESCRIPTION DRUGS
MAIL-ORDER PRESCRIPTION DRUGS
Annual Prescription
Deductible
Tier 1: Generic
Tier 2: Formulary Brand-Name
Tier 3: Non-Formulary Brand-Name and
Brand Non-Sedating Antihistamines
Dispensing Limits Per
Copayment
High Deductible Health Plan/Health Savings Account
RETAIL PRESCRIPTION DRUGS
MAIL-ORDER PRESCRIPTION DRUGS
Annual Prescription
Deductible
Combined With Medical
Tier 1: Generic
Tier 2: Formulary Brand-Name
Tier 3: Non-Formulary Brand-Name and
Brand Non-Sedating Antihistamines
Paper Claims Reimbursement
You must pay the full price at the pharmacy and file a claim for reimbursement, as outlined in the “Pharmacy Benefits” section of this Handbook. You will be reimbursed according to what the Plan would have paid at a participating pharmacy, less your applicable copayment. Dispensing Limits Per
Copayment
Coverage of Non-Sedating Antihistamines
The non-sedating antihistamine drug category has the highest copayment, regardless of the drug’s formulary status. This change is a re-sult of the drug Claritin now being available over the counter. For example, if you prefer to take the medication Clarinex rather than buy-ing Claritin over the counter, you pay the third-tier copayment.
Generic Substitution Requirement
Generic medications and their brand-name counterparts have the same active ingredients and are manufactured according to the same
strict federal regulations. Generic drugs may differ in color, size, or shape, but the U.S. Food and Drug Administration (FDA) requires that
the active ingredients have the same strength, purity, and quality as their brand-name counterparts. For this reason, the Plan will
cover the cost of the generic equivalent if you purchase a brand-name medication when there is a generic available. You will be
charged the generic copayment and the cost difference between the brand-name and the generic medication. If you have ques-
tions or concerns about generic medication, speak to your physician or your pharmacist, and he or she will be able to help you.
Prescriptions Filled At A Nonparticipating Pharmacy
If you go to a retail pharmacy that is not part of the Medco network, you must pay the full cost of the prescription and then submit a di-
rect reimbursement claim form to Medco. You will be reimbursed for the amount the medication would have cost your Plan at a partici-
pating pharmacy minus the copayment you would have paid.
Keep in mind, the retail pharmacy program allows for a total of three fills of a maintenance medication at a retail phar-
macy (one original fill and two refills). Additional fills will not be covered by the Plan. Each fill can be for no more than a
30-day supply. Note that you are allowed a total of three fills, even if each is for less than 30 days.
Retail Refill Limit
The Prescription Drug Program will maintain a Retail Refill Limit policy. The retail refill limit requires that you use the mail-order pharmacy if you are prescribed a maintenance medication, rather than refilling multiple prescriptions for the samedrug at a retail pharmacy. If you or a covered dependent receives a prescription for a maintenance medication and you donot use the mail-order pharmacy, your prescriptions may not be covered.
In some circumstances, you may not be required to use the mail-order pharmacy. For example, there are several cate-gories of medications that are uniquely appropriate for multiple refills at your local pharmacy (and are therefore exemptfrom the mandatory mail-order provision, as outlined above). If you have a prescription for any of the following medica-tions, the Prescription Drug Program allows you to receive multiple refills at your local retail pharmacy: • Anti-infectives, including antibiotics (Amoxicillin, Biaxin), antivirals (Zovirax, Famvir), antifungals (Diflucan), and drops used in the eyes and ears (Polsporin Opth, Cipro Otic). Please note that drops must be prescribed specif-ically to treat infection. For example, glaucoma drops are not covered.
• Prescription cough medications, including Phenergan with Codeine, Tessalon, and Tussionex. • Medications to treat acute pain, both narcotic (Vicodin, Percodan, etc.) and non-narcotic (Darvocet). Please note that long-term pain medications, such as NSAIDs, do not meet the necessary retail requirements.
• Medications that require a new written prescription each time you need them, as refills are prohibited by federal law (e.g., Percodan, Ritalin, and Nembutal).
• Medications used to treat both attention deficit disorder (Ritalin, Cylert) and narcolepsy (Dexedrine).
• Medications whose sole use is to treat cancer.
Refilling Mail-Order Prescriptions
Since your medication can take 7 to 11 days to be delivered, you should have at least a 14-day supply of that medication on hand to hold
you over. If you do not have enough medication, you may need to ask your doctor for another prescription for a 14-day supply that you can
fill at your local retail network pharmacy.
Your Plan May Have Coverage Limits
Your Plan may have certain coverage limits. For example, prescription drugs used for cosmetic purposes may not be covered, or a medica-tion might be limited to a certain amount (such as the number of pills or total dosage) within a specific time period.
If you submit a prescription for a drug that has coverage limits, your pharmacist will tell you that approval is needed before the prescriptioncan be filled. The pharmacist will give you or your doctor a toll-free number to call. If you use Medco By Mail, your doctor will be contacteddirectly.
When a coverage limit is triggered, more information is needed to determine whether your use of the medication meets your Plan’s coverageconditions. We will notify you and your doctor of the decision in writing. If coverage is approved, the letter will indicate the amount of time forwhich coverage is valid. If coverage is denied, an explanation will be provided, along with instructions on how to submit an appeal.
Additional Information
It is always up to you and your doctor to decide which prescriptions are best for you. You are never required to use generic drugs or drugsthat are on the Medco formulary list. If you prefer, you can use non-formulary brand-name drugs and pay a higher copayment.
It is also important to note that drugs included on the formulary list are routinely updated. To find the most up-to-date list of covered drugs,
visit Medco at www.medco.com, or call their member services department at (800) 841-3361. It should be noted that all drugs listed on the
formulary may not be covered due to Plan exclusions and limitations. You can also use Medco’s Web site or member services telephone num-
ber to locate the retail pharmacy nearest you.
Paper Claims Reimbursement
You must pay the full price at the pharmacy and file a claim for reimbursement. You will be reimbursed according to what the Plan wouldhave paid at a participating pharmacy, less your applicable copayment. See the “Pharmacy Benefits” section of your Plan Handbook formore information about filing claims for reimbursement for prescription drugs purchased at retail pharmacies.
Medco toll-free number: (800) 841-3361
NOTES: Some prescriptions may require prior authorization. Please refer to the “Pharmacy Benefits” section of this Handbook for further in-
Prescription deductibles and copayments do not apply to the medical plan deductibles or out-of-pocket maximums.

Source: http://www.dioceselongisland.org/hr/2012_Medco_Summary.pdf