Health and Welfare Summary Plan Description

• Health and Welfare SPD / Article VIII / Self-Funded PPO Option >>

8.5 Prescription Drug Card Program

1. Administered by OptumRx. The prescription drug card program for Covered Individuals under the Self-Funded PPO is administered by OptumRx, which is a pharmacy benefit manager.
   1. OptumRx Identification Cards. Shortly after you become eligible, OptumRx will provide you an identification card that you must present at a network pharmacy each time you purchase a prescription. You may order additional cards by calling OptumRx at (888) 354-0090 or (800) 356-3477.
      
      
   2. OptumRx Participating Pharmacies. Most major chains and independent pharmacies are in the OptumRx pharmacy network, including Lucky, Costco, K-Mart, CVS, Raley's, Safeway, Save Mart, Save-on, Shopko, RiteAid, Target, Von's Food & Drug, Walgreens, and Wal-Mart.
      
      To locate a participating pharmacy closest to your home or workplace, call the OptumRx Help Desk at (888) 354-0090 and request a zip code search. Or you can locate this information online by accessing OptumRx.com.
2. Benefits. You may receive benefits under the Self-Funded PPO prescription drug program through a retail pharmacy, by mail order or by direct reimbursement.
   1. Retail Pharmacy. Participant coinsurance collected at Pharmacy:
      

      Generic Drug	Lesser of 20% of retail price or $7/script
      Brand Name Drug	20% of retail price

      30-day maximum supply allowed with each prescription.
      
      
   2. Mail Order (Recommended for Maintenance Medications). Participant coinsurance paid by check or credit/debit card:
      

      Generic Drug	Lesser of 20% of retail price or $17.50/script
      Brand Name Drug	20% of retail price

      90-day maximum supply allowed with each prescription with up to three refills if appropriate.
   3. Special Pharmacy.Participant co-insurance/copayment paid by check or credit/debit card
      

      Generic Drug	Lesser of 20% of Specialty price or $150.00/script
      Brand Name Drug	Lesser of 20% of Specialty price or $150/script

3. Covered Drugs. Drugs covered under the prescription drug card program include federal legend drugs (drugs approved by the FDA requiring a written prescription), bee sting kits, Depo Provera, diabetic test strips, lancets, diaphragms, glucogan, immunosuppressants, insulin/syringes (must be on a written prescription), one glucose meter per year, acne/dermatological products (through age 40 with prior authorization), Viagra (limit 8 tablets/30 days) and vitamins (prescription only). If cost of compund medication exceeds $200 per prescription, prior authorization is required. Certain medications may be subject o quantity level limits and/or dosing limits.
   
   
4. Excluded Drugs. Drugs not covered under the prescription drug card program include appetite suppressants/weight loss agent, blood and blood plasma*, cosmetic drugs, drugs and devices administered at the doctor's office, rest home or hospital, fertility drugs, growth hormones, immunization* and vaccinations*, injectables not self-administered or otherwise available through the specialty drug program described below*, medical supplies and appliances*, over-the-counter products (with the exception of proton pump inhibitors and non-sedating antihistamines with a written prescription, as described below) and over-the-counter vitamins and nutritional products. To the extent that any of the items in this subsection are considered preventive care and provided under subsection (e) below, they will not be excluded.
   * Note: items with an asterisk are covered under the Self-Funded PPO.
   
   
5. Preventive Care. The Plan pays 100% of the cost for several Preventive Care medications. You will not be charged a copayment for specific over-the-counter drugs, supplements and immunizations described below if you or your covered family member meets the age limits or other requirements. You should request a prescription from your physician, and in cases where coverage only applies to generics or over-the-counter medications, make sure to request a generic or over-the-counter prescription. Present your pharmacy ID card and your prescription to your pharmacy, and the pharmacy will process your prescription without a copay. The following is a partial list of Preventive Care prescriptions:
   1. Aspirin (325 mg. or less) for men and women beginning at age 45.
   2. Contraceptives:
      1. over-the-counter female contraceptive products;
      2. prescription contraceptive drugs; and
      3. prescription contraceptive devices.
   3. Folic acid supplements and prenatal vitamins for women younger than 55.
   4. Immunization vaccines.
   5. Iron Supplements for children ages 6 months to 12 months.
   6. Oral fluoride supplements for children ages 6 months to 6 years.
   7. Shingles vaccine for adults age 50 and older.
      A complete list of Preventive Care health services, including over-the-counter drugs, supplements, and immunizations can be found at HealthCare.gov/center/regulations/prevention.html.
6. Direct Member Reimbursements. New members may submit claims for prescriptions not billed through OptumRx by filling out a Direct Member Reimbursement Claim Form (you can locate forms at OptumRx.com). Direct member reimbursements submitted within the first 60 days of eligibility under the Plan will be paid at amount claimed minus the copayment. Direct member reimbursements submitted after the first 60 days of eligibility will be paid at the contracted rate minus the copayment. Please remember to always use your prescription drug card when obtaining your medications.
   
   
7. Coordination of Benefits. If you have other prescription drug coverage through another group provider that is primary, the Plan, as secondary carrier, will coordinate benefits by reimbursing you for the primary plan's out-of-pocket copayment. This can be done at the retail pharmacy by using your prescription card for your primary carrier and then your Plan prescription coverage card as secondary carrier. If you do not have your SFEW prescription coverage card when the pharmacist fills your prescription, you may also seek reimbursement by submitting a Direct Member Reimbursement Form to OptumRx with your receipt showing the amount you paid and the amount your primary insurance paid.
   
   
8. Over-The-Counter (OTC) Program Options for Proton Pump Inhibitors (PPIs) and Non-Sedating Antihistamines (NSAs). The Plan will cover the full cost of prescription strength PPIs (OTC Prilosec, Omeprazole, Prevacid, and Zegerid) and NSAs (OTC Claritin, Alavert, Claritin D, Allegra, Allegra-D, Zyrtec, and Zyrtec-D) over-the-counter ("OTC") for no copayment, provided you have a prescription. In order to have the $0 copayment apply, you will need to present your prescription drug card, the OTC medication and your prescription from your doctor to the pharmacist. Your pharmacist can call your doctor for a prescription, but you must present your drug card to the pharmacy in order to have the $0 copayment apply. This program is optional.
   
   
9. Specialty Drug Program. This program provides one-on-one service and active management of biopharmaceuticals (e.g. Infertility Agents, Hepatitis C), and a more cost effective solution for specialty medications. A "Member Care Specialist" is assigned to contact individuals who have been prescribed certain medications to make sure that they are taking them, as prescribed, and understand how to deal with any side effects that may occur. These medications are sent directly to the members' homes, and clinical pharmacists that are dedicated to the specialty pharmacy are available on a 24-hour basis to answer questions or concerns. Participant coinsurance, under this program, is 20%, up to a maximum of $150 per script. Prior authorizatin will be required on all specialty categories to the market.
   
   
10. Step Therapy and Dispense as Written (DAW) Medications The Self-Funded PPO prescription drug program includes a "step therapy" program for select drugs. Step therapy is an automated program that a pharmacist uses to review a patient's medication history, often resulting in an alternative (sometimes generic) medication to replace a more costly brand medication. The program requires a patient to try a clinically appropriate, lower cost medication first, or an equivalent unless a physician provides medical documentation that a patient has tried and failed an alternative (generic) medication in the recent past.
    1. Generic Incentive Program. The "generic incentive" program promotes the use of FDA-approved generic medications. The program concentrates on brand prescription medications that have equivalent (the same active ingredient) generics available and require a patient to try the equivalent generic first. If a covered individual chooses not to participate in the generic incentive program that individual will be required to pay the applicable copayment described above plus the total cost difference between the brand and the equivalent generic, unless clinical documentation from the prescribing physician indicates the reason the generic medication cannot be tolerated.
       
       Note: These penalties will not apply to higher cost drugs that were initially prescribed before August 1, 2011.
       
       
    Quantity Level Limits and dosing limits. Certain medications have quantity level limits and/or quantity duration management per day supply based on the FDA recommended dosing guidelines. These medications also include the classification such as Hepatitis C treatment, migraine medications, sleep aids, pain managment medications, opiods and narcotics. These agents have a quantity per day supply as well as a duration management.
    2. Opiod Management Program. The Plan uses OptumRx to provide opiod managment services. For home delivery, the program requires electronic prescriptions to fill controlled substances, and limits dispensation of opiod prescription to a maximum 30-day supply. If you need to dispose of excess supply of opiods, please contact OptumRx to obtain a drug disposal kit.
    3. Medical Exception and Clinical Appeals. An exception process is available for members that have experienced an adverse drug reaction (ADR) while using generic prescription medication under the care of a physician. The prescribing physician may request a medical or clinical exception on behalf of a member when providing clinical documentation including the generic name, adverse drug reaction experienced and the date of fill for an exception to be approved. Please have your physician provide a letter of medical necessity with this information. Contact numbers for the physician to contact the OptumRx Prior Authorization Department are as follows:
       • (800) 527-0531 (Fax)
       • (800) 711-4555 (Tel)
    4. Information: Telephone/Websites/ Mail Order Address. For your reference, you may also access the FDA's website for comprehensive information about generic drugs:
       
       http://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/UnderstandingGenericDrugs/default.htm.
       

       OptumRx Website:	OptumRx.com
       OptumRx Help Desk:	(888) 354-0090
       OptumRx Mail Order Help Desk:	(800) 797-9791
       OptumRx Mail:	P.O. Box 509075 San Diego, CA 92150-9075