Prescription Drug Plan
Covered prescriptions obtained at retail through a participating pharmacy are subject to the following deductible and copayments:
- Deductible: $50 per person, per year. (The deductible is for retail and mail order service prescriptions.)
- The copays for a participating retail pharmacy (30 day supply) are as follows:
- Generic Drug - $10.00
- Formulary Brand Name Drug - $20.00 or 20% of cost, whichever is greater, up
to a maximum of $50
- Non-Formulary Brand Name Drug- $40.00 or 30% of cost, whichever is greater,
up to a maximum of $50.
ITEMS COVERED UNDER THE PLAN INCLUDE:
- Drugs which, under Federal law, are required to bear the legend "Caution: Federal law prohibits dispensing without prescription";
- Compound medications which contain at least one ingredient that is a prescription legend drug;
- Injectable insulin and other injectable drugs except those specifically excluded;
- Diabetic supplies including lancets, test strips, and syringes/needles.
MAIL ORDER SERVICE
The mail order service allows the individual to obtain a three-month supply of maintenance medication. A maintenance medication is a prescription used to treat a condition that requires a member to take it frequently or over a period of time. This will require an employee to obtain a script for a prescription from their physician and send it along with a payment to the prescription plan mail order service. The mail order service will apply the deductible (if applicable) and co-payments to all orders, and they will process it within seven (7) to 14 business days after receipt of the order. Members may also order refills online, by mail or telephone and receive the order within three (3) to five (5) business days. An advantage of the mail order service is it allows a member to save money on co-payments and lowers the monthly cost.
Please note that the prescription plan has a mandatory mail order requirement. This requirement will allow you to get two fills for a maintenance medication at the retail pharmacy for the retail co-payments. After the second fill, the prescription plan will provide no coverage for the maintenance medication at the retail pharmacy and you will have to submit your prescription(s) to Medco-by-Mail for coverage of the medication.
The copay (90 day supply) for the mail order service are as follows:
- Generic Drug - $20
- Formulary Brand Name Drug - $40.00 or 20% of cost, whichever is greater, up to a
maximum of $100
- Non-Formulary Brand Name Drug- $80.00 or 30% of cost, whichever is greater, up to
a maximum of $100.
Note: Prenatal Vitamins are covered only through the mail order service with the applicable co-payment.
The prescription plan has the following programs:
Mandatory Generic Requirement
The prescription plan has a mandatory generic requirement that provides coverage of a generic only for brand medications with a generic alternative. A plan participant can still opt to receive a brand medication; however, the prescription plan will only provide coverage that equates to the amount of the generic alternative. The plan participant will be responsible for the copayment for the generic plus the cost difference between the brand and generic medication.
Preferred Drug Step Therapy (PDST) Program
The PDST program targets certain drugs in specified categories that are interchangeable with good generic alternatives. A plan participant will only receive coverage under the plan for the generic alternative if a provider writes a prescription for a specific brand medication that falls in the category of the PDST. You may call Medco on the telephone number listed below to obtain more information about the program or to obtain a list of the targeted drug categories.
Prior Authorization Program
The Prior Authorization program requires a physician review to ensure that the requested medication is being used appropriately for certain drug categories. The County currently has this program in place on various drug categories. You may contact Medco on the telephone number below to find out if your medication falls in this category.
EXCLUSIONS FROM COVERAGE
Items not covered include:
- Drugs obtained without a prescription.
- Drugs that exceed a 30-day supply cannot be processed at the retail pharmacy.
- Vitamins or minerals, (except Prenatal vitamins which may be obtained through the mail order service).
- Drugs charged by any hospital, rest home, sanitarium, or similar institution.
- Immunization agents, biological sera, blood or blood plasma, beauty aids, cosmetics and dietary supplements.
- Drugs covered under any governmental program or law or for which no charge is incurred or for which there is no legal obligation to pay.
- Drugs prescribed as a result of work-related injuries or disease. (Contact Worker’s Compensation carrier)
- Drugs prescribed as a result of war-related injuries or disease.
- Drugs not approved by the Federal Drug Administration, including but not limited experimental drugs.
- Drugs, which are not medically necessary.
Prescription Plan Opt-Out Provision:
The County offers employees who have other prescription coverage the opportunity to earn credits. The prescription opt-out credit is $7.69 per payday or $200 annually and proof of coverage is not required. However, you must submit an Enrollment/Change Form each year during Open Enrollment to renew these credits.
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