Attachment # 1: Benefits Summary Documents
Attachment # 1: Benefits Summary Documents
Attachment # 1: Benefits Summary Documents
Attachment # 1: Benefits Summary Documents
Attachment # 1: Benefits Summary Documents
PRESCRIPTION DRUG BENEFIT SUMMARY
Administered by Express Scripts
Toll-free: 1-800-498-4904
Effective Date of Coverage: July 1, 2013
Local Participating Pharmacy
(EXCLUDES ALL WALGREENS
PHARMACIES)
Mail-Order
Pharmacy
Maximum days’ supply
per copay
30 days
90 days
Generic drugs (includes OTC
Claritin®, Allegra, Alavert®, and
Prilosec OTC®.(Prescription
required.)
$3 copay
$7.50 copay
Preventative products under
the Patient Protection & Affordable Care Act. (Prescription
required. To confirm products
covered, contact Member
Services at 1-800-498-4904.)
$0 copay
$0 copay
Preferred diabetes medications
and supplies
To confirm copay or coverage
of insulin or diabetes supplies,
visit ÜÜÜ°iÝ«ÀiÃÇÃVÀˆ«ÌðVœ“
or contact Member Services at
1-800-498-4904.
To confirm copay or coverage
of insulin or diabetes supplies,
visit ÜÜÜ°iÝ«ÀiÃÇÃVÀˆ«ÌðVœ“
or contact Member Services at
1-800-498-4904.
Preferred brand-name drugs
30% of the discounted cost;
minimum payment of $18 and
maximum payment of $50
$45 copay
Nonpreferred drugs
70% copay
70% copay
Visit ÜÜÜ°iÝ«ÀiÃÇÃVÀˆ«ÌðVœ“
to view the current formulary,
obtain copay cost estimates,
and find less costly alternatives
for your doctor’s review.
Visit ÜÜÜ°iÝ«ÀiÃÇÃVÀˆ«ÌðVœ“
to view the current formulary,
obtain copay cost estimates, and
find less costly alternatives for
your doctor’s review.
Specialty drugs
$75 copay for a 30-day supply.
After specialty copays add up
to $750, copays are reduced for
the remainder of the calendar
year. ($7.50 generic, $45
preferred, 70% nonpreferred).
Specialty drugs are obtained
via the contracted specialty
pharmacy after the second fill at
retail.
Immunizations administered
by certified pharmacists. (See
definitions in this Section.)
$0 copay
Not covered at mail order.
To locate a certified pharmacist,
visit …ÌÌ«Ã\Éɘ“«Ãˆ>°Vœ“É
ExpressScripts.html or contact
Member Services at
1-800-498-4904.
Only available from local,
certified pharmacist. Visit …ÌÌ«Ã\ÉÉ
˜“«Ãˆ>°Vœ“ÉÝ«ÀiÃÃÊ-VÀˆ«Ìð
html or contact Member Services
at 1-800-498-4904.
New Mexico Public Schools Insurance Authority
35
P R O G R A M
G U I D E
J U L Y
2 0 1 3
Attachment # 1: Benefits Summary Documents
PRESCRIPTION DRUG BENEFIT SUMMARY
Administered by Express Scripts
Toll-free: 1-800-498-4904
Effective Date of Coverage: July 1, 2013
WALGREENS PHARMACIES ONLY
Maximum days’ supply
per copay
30 days
Generic drugs (includes
OTC Claritin®, Allegra,
Alavert®, and Prilosec OTC®.
(Prescription required.)
$8 copay
Preventative products
under the Patient Protection
and Affordable Care Act.
(Prescription required.
To confirm products covered,
contact Member Services at
1-800-498-4904.)
$0 copay
Preferred diabetes
medications and supplies
Not eligible for copay waiver at Walgreens. Customary
copays apply.
Preferred brand-name drugs
30% of the discounted cost; minimum payment of $23 and
maximum payment of $55
Nonpreferred drugs
70% copay
Visit ÜÜÜ°iÝ«ÀiÃÇÃVÀˆ«ÌðVœ“ to view the current
formulary, obtain copay cost estimates, and find less costly
alternatives for your doctor’s review.
Specialty drugs
$75 copay for a 30-day supply.
After specialty copays add up to $750, copays are reduced
for the remainder of the calendar year.
($7.50 generic, $45 preferred, 70% nonpreferred).
Specialty drugs are obtained via the contracted specialty
pharmacy after the second fill at retail.
Immunizations administered
by certified pharmacists
36
New Mexico Public Schools Insurance Authority
To locate a certified pharmacist, visit …ÌÌ«Ã\Éɘ“«Ãˆ>°Vœ“É
ExpressScripts.html or contact Member Services at 1-800498-4904