Express Scripts
Prescription Drug Program
January 1, 2015
Prescription Drug Services
Option 1, Option 2 and Option 3
Annual Out-of-Pocket Maximum
$1,500 Individual/$3,000 Family
Retail Prescription Drugs
(30 day supply)
Generic Drugs
$10.00 copayment
Deductible does not apply
Preferred Brand Drugs
30% coinsurance with Minimum $35 and Maximum $70
Non-Preferred Drugs
50% coinsurance with Minimum $55 and Maximum $110
Out of Network Drugs
NOT COVERED
Women Contraceptives
(birth control for Women through age of 50)
Generic and Single Source Brand Drugs
You pay 0% - 100% coverage
Coverage includes the following (Generic/Single Source/Multi-Source Dispense as
Written by Physician (DAW1) – RX and Over the Counter)
$0 copay applies within the standard age and gender limits.
•
Barrier contraceptive method – diaphragms/cervical caps
•
Hormonal contraceptive methods – oral, transdermal,
intravaginal injectable hormonal contraceptives
•
Emergency contraceptive method – e.g. Plan B and Ella
•
Implantable medications – e.g. Implanon
•
Intrauterine contraceptives – e.g. Mirena, Skyla
•
OTC contraceptives (with a prescription)
Preferred Brand Drugs
30% coinsurance with Minimum $35 and Maximum $70
Please see explanation under Generic and Single Source Brands
Non-Preferred Drugs
50% coinsurance with Minimum $55 and Maximum $110
Please see explanation under Generic and Single Source Brands
Out of Network Drugs
NOT COVERED
Disposable Diabetic Supplies
Includes, but is not limited to, test strips,
syringes and lancets
Generic Drugs
$10.00 copayment
Preferred Brand Drugs
30% coinsurance with Minimum $35 and Maximum $70
Non-Preferred Drugs
50% coinsurance with Minimum $55 and Maximum $110
Out of Network Drugs
NOT COVERED
Drugs for Treatment of Infertility
Deductible does not apply
Drugs for the treatment of sexual dysfunction are
limited to 8 units per 30 days or 24 units per 90
days.
See Retail or Specialty Drugs
Prescription Drug Service
Option 1, Option 2 and Option 3
Home Delivery Prescription Drugs
(90 day supply)
Generic Drugs
$25.00 copayment
Deductible does not apply
Preferred Brand Drugs
30% coinsurance with Minimum $70 and Maximum $135
For information on how to obtain drugs through
the Express Script home delivery service, go to
Express-Scripts.com
Non-Preferred Drugs
50% coinsurance with Minimum $115 and Maximum $225
Women Contraceptives
(birth control for Women through age of 50)
Generic and Single Source Brand Drugs
You pay 0% - 100% coverage
Coverage includes the following (Generic/Single Source/Multi-Source
Dispense as Written by Physician (DAW1) – RX and Over the Counter)
$0 copay applies within the standard age and gender limits.
• Barrier contraceptive method – diaphragms/cervical caps
• Hormonal contraceptive methods – oral, transdermal,
intravaginal injectable hormonal contraceptives
• Emergency contraceptive method – e.g. Plan B and Ella
• Implantable medications – e.g.Implanon
• Intrauterine contraceptives – e.g. Mirena, Skyla
• OTC contraceptives (with a prescription)
Preferred Brand Drugs
30% coinsurance with Minimum $70 and Maximum $135
Please see explanation under Generic and Single Source Brands
Non-Preferred Drugs
50% coinsurance with Minimum $115 and Maximum $225
Please see explanation under Generic and Single Source Brands
Express Scripts Extended Retail Network
(31-60 and 61–90 day supply)
No Coverage
Preventive Care Drugs
Medications published by the Federal
Government (subject to change) with a valid
prescription
You pay 0% - 100% Coverage
Deductible does not apply
•
•
•
•
•
•
•
Drugs for Treatment of Infertility
Deductible does not apply
Drugs for the treatment of sexual dysfunction are
limited to 8 units per 30 days or 24 units per 90
days.
Aspirin, Generic OTC, products < or = 325mg (men age 45 to 79
and women 55 to 79)
Folic-Acid, Generic OTC and Generic RX (0.4 – 0.8 mg strengths
for women up to age 50)
Iron Supplements, Generic OTC and Generic RX Only (birth
through 12 months of age)
Fluoride, Generic OTC and Generic RX when available (birth
through age of 5 years)
Smoking Cessation Products, Generic Rx and Generic OTC only,
plus Chantix (over age 18)
Immunizations
Travel Vaccines
See Retail or Specialty Drugs
Prescription Drug Service
Option 1, Option 2 and Option 3
Specialty Drugs - Self-Administered
(up to 30-day supply)
Generic Drugs
$25.00 copayment
Deductible does not apply
Preferred Brand Drugs
30% coinsurance with Minimum $70 and Maximum $135
Non-Preferred Drugs
50% coinsurance with Minimum $115 and Maximum $225
Important information for those who use specialty medications
Specialty medications are drugs that are used to treat complex conditions, such as cancer, growth hormone deficiency, hemophilia,
hepatitis C, immune deficiency, multiple sclerosis, and rheumatoid arthritis. Whether they’re administered by a healthcare
professional, self-injected, or taken by mouth, specialty medications require an enhanced level of service.
The Searles Valley Minerals Inc. Group Welfare Plan prescription drug plan requires that certain specialty medications be accessed
through Accredo Health Group, Inc., Express Scripts’ specialty pharmacy. The list of medications subject to this specialty drug
program may change, and you should check the list before you fill a prescription for a specialty medication. If you are currently using
a retail pharmacy to obtain specialty medications that are on the program list, you will be required to transfer those prescriptions to
Accredo. If you continue to purchase your medications from a pharmacy other than Accredo, you will be responsible for their full
cost.
To confirm whether a medication you take is part of the specialty program, call 800-818-6721 or log in to your account at ExpressScripts.com. If you would like to learn more about specialty medications and services, visit Accredo.com.
Step Therapy
This program is a “step” approach to providing drug coverage. It is designed to encourage the use of cost-effective prescription
drugs when appropriate. This means that you may first need to try an alternative drug, typically a generic, before the plan will cover
certain medications prescribed by your physician. Step Therapy programs are developed using Food and Drug Administration
(FDA) guidelines, clinical evidence and research. They ensure that you are taking appropriate and cost-effective medications. If
you are prescribed an eligible Step Therapy medication, another eligible medication in the same or different drug class must have
been prescribed or tried (i.e. generic drug/first step) before the Step Therapy medication (i.e. brand drug/second step) will be paid
under the drug benefit.
To find out of the drug you were prescribed is subject to a Step Therapy program, you can contact Member Services at
800.818.6721or visit Express-Scripts.com.
Unless otherwise specified above in the Prescription Drug Services section, you may receive up to 30-day supply per prescription.
However, certain drugs may be subject to any quantity limits applied as a part of the drug utilization review process. A 90-day
supply will be covered and dispensed at a time only through Express Scripts Home delivery. No more than a 30-day supply of
specialty drugs will be covered and dispensed at a time.
Brand Name Medication with Generic Equivalent
When you choose a brand-name medication for a generic equivalent or your doctor prescribes a brand-name medication by indicating
dispense as written (DAW) on your prescription, you will receive the brand-name medication – but it will cost you more. You will
pay the applicable brand copayment, plus the difference in cost between the brand and generic. This applies to new and existing
prescriptions.
How the Prescription Drug Feature Works
You will receive a prescription drug card that you must show at participating pharmacies. If you need a replacement ID card, contact
member services or Express-Scripts.com for a new card or temporary card. You can also visit Express-Scripts.com or contact member
services at 800.818.6721for a list of pharmacies. Here is how you buy covered prescription drugs at a participating pharmacy under
the Plan:
•
•
You present your prescription drug card to the participating pharmacy when you need a prescription filled. You pay the
pharmacy only the amount of your coinsurance or copayment, which may include deductible amounts if applicable under
your plan. The pharmacy will then file a claim with Express Scripts for the balance. When prescription claims are processed
electronically to Express Scripts from the pharmacy, you will not need to file a claim form.
Coordination of Benefits (COB) is not performed on prescription claims.
Home Delivery through The Express Scripts PharmacySM
The Express Scripts home delivery pharmacy service is designed for plan participants taking maintenance medications, or those
medications taken on a regular basis, for the treatment of long-term conditions such as diabetes, arthritis or heart conditions. The
program provides up to a 90-day supply of medication, delivered directly to your home or other requested location, postage paid.
In order to fill your prescription through the home delivery, mail your prescription, order form and payment. You may also ask your
doctor to fax your prescription by calling 888.327.9791 for further instruction. Your medication will usually be delivered within 8
days of Express Scripts receiving your order.
To order refills, call the automated refill system at 1.800.REFILL (1.800-473.3455), or visit Express-Scripts.com. Refills are
normally delivered within 3 to 5 days.
If you are a first-time visitor to the site please take a moment to register. You will need to have your member ID available.
To ensure timely delivery, please place your orders at least two weeks in advance to allow for mail delays and other circumstances
beyond our control. If you have any questions concerning your order, or if you do not receive your medication within the designated
timeframe, please contact Member Services.
If a new medication has been prescribed for you to take immediately, please ask your doctor to issue two prescriptions; one
prescription should be written and filled at your local pharmacy and the second should be written for up to a 90-day supply and mailed
to Express Scripts home delivery.
As you manage your prescriptions, please be aware that each and every prescription is filled and checked by highly qualified
registered pharmacists to ensure that quantity, quality and strength are accurate. A patient profile is maintained on file to ensure that
there are no adverse reactions with other prescriptions you are receiving from retail and/or home delivery pharmacies. If any
questions arise regarding potential drug interactions or other adverse reactions, Express Scripts’ pharmacists will contact either you or
your doctor prior to dispensing the medication.
Covered Medications
•
•
•
•
Federal legend prescription drugs, unless otherwise indicated;
Drugs requiring a prescription under the applicable state law;
Insulin, insulin needles and syringes on prescription; or
Compound medications, of which at least one ingredient is a federal legend drug.
Medications Not Covered
If any expense not covered is contrary to any law to which the Plan is subject, the provision is hereby automatically changed to meet
the law’s minimum requirement. No payment will be made under any portion of the Plan for:
•
•
•
•
•
•
•
•
•
•
A drug that can be purchased without a prescription order; these are commonly called over-the-counter (OTC) drugs;
Therapeutic devices or appliances, support garments and other non-medical devices;
Medication that is to be taken by or administered to a Plan participant, in whole or in part, while the Plan participant is a
patient in a hospital, rest home, sanitarium, extended care facility, convalescent hospital, nursing home, or similar institution
that operates on its premises a facility for dispensing pharmaceuticals;
Investigational or experimental drugs; including compounded medications for non-FDA approved use;
Prescriptions that a Plan participant is entitled to receive without charge under any Worker’s Compensation law or any
municipal state or federal program;
Hair growth stimulants;
Drugs prescribed to remove or reduce wrinkles in the skin;
Appetite suppressants or any drug used for weight loss; unless pre-authorized;
Fertility medications, except as specified in this SPD;
Nutritional supplements;
•
•
•
•
•
•
•
•
•
•
•
•
Ostomy supplies;
Topical fluoride products;
Non-systemic prescription contraceptives;
Growth hormones; unless pre-authorized;
Implantable, time-released medications;
Injectibles (contact Express Scripts for a list of exceptions);
Charges for the administration or injection of any drug;
Biologicals/Vaccines/Immunization agents, except as specified in this SPD;
Plasma/Blood Products (Except hemophilia factors);
Allergy serums;
Any prescription filled in excess of the number of specified by the doctor or any refill dispensed after one year from the
doctor’s original order; and
Drugs with cosmetic implications.
Medications Requiring Prior Authorization through Express Scripts
Some medications are not covered unless you first receive approval through a coverage review (prior authorization). This review uses
Plan rules based on FDA-approved prescribing and safety information, clinical guidelines, and uses that are considered reasonable,
safe and effective.
There are other medications that may be covered, but with limits (for example, only for a certain amount or for certain uses), unless
you receive approval through a coverage review. During this review, Express Scripts asks your doctor for more information than what
is on the prescription before the medication may be covered under your Plan. To find out whether a medication requires a coverage
review, log in to Express-Scripts.com anytime, select Price a Medication from the drop-down menu under "Manage Prescriptions" and
search for your medication.
Even if you receive prior authorization for your prescription, some medications are still subject to special dosage and quantity
limitations, regardless of what your physician prescribes.
Drug Limitations
Some medications are only covered under the Plan subject to special dosage and quantity limitations. The limits are based on
clinically approved prescribing guidelines and are routinely reviewed by Express Scripts to ensure clinical appropriateness.
Your pharmacists will inform you if a particular medication is subject to dosage or quantity limitations. The Plan will not cover the
cost of medications beyond the dosage or quantity limitations unless prior authorization is obtained. Your doctor will initiate the prior
authorization process for you. If prior authorization is denied, you will be required to pay the full cost of the medication beyond the
dosage or quantity limitations at the time you fill your prescription. You may file an appeal using the process described in the
“Prescription Claim & Appeal Procedures” section of this summary.
You can find out if your prescription drug is subject to limitations by calling member services or visiting Express-Scripts.com.
Prescription Claim and Appeal Procedures
Claims should be submitted to Express Scripts at
Mail To:
Address:
EXPRESS SCRIPTS
PO BOX 66587
City, State, Zip:
Attention:
Phone #:
ST. LOUIS, MO 63166-6587
ATTN: ADMINISTRATIVE APPEALS DEPARTMENT
800-818-6721
Express Scripts will make an initial determination of a claim for benefits (and notify you of the decision) within 30 days. This time
period may be extended for an additional 15 days, provided that Express Scripts determines that such an extension is necessary due to
matters beyond the control of the Plan. If such extension is necessary, you will be notified prior to the expiration of the initial 30-day
period.
In the event you receive an adverse benefit determination following a request for coverage of a prescription benefit claim, you have
the right to appeal the adverse benefit determination in writing within 180 days of receipt of notice of the initial coverage decision.
An appeal may be initiated by you or your authorized representative (such as your physician). To initiate an appeal for coverage,
provide in writing your name, member ID, phone number, the prescription drug for which benefit coverage has been denied, the
diagnosis code and treatment codes to which the prescription relates (together with the corresponding explanation for those codes) and
any additional information that may be relevant to your appeal. This information should be mailed to Express Scripts,
Mail To:
Address:
EXPRESS SCRIPTS
PO BOX 66587
City, State, Zip:
Attention:
Phone #:
ST. LOUIS, MO 63166-6587
ATTN: ADMINISTRATIVE APPEALS DEPARTMENT
(800) 818-6721
A decision regarding your appeal will be sent to you within 15 days of receipt of your written request. The notice will include
information to identify the claim involved, the specific reasons for the decision, new or additional evidence, if any considered by the
Plan in relation to your appeal, the Plan provisions on which the decision is based, a description of applicable internal and external
review processes and contact information for an office of consumer assistance or ombudsman (if any) that might be available to assist
you with the claims and appeals processes and any additional information needed to perfect your claim. You have the right to receive,
upon request and at no charge, the information used to review your appeal.
If you are not satisfied with the coverage decision made on appeal, you may request in writing, within 90 days of the receipt of notice
of the decision, a second level appeal. A second level appeal may be initiated by you or your authorized representative (such as your
physician). To initiate a second level appeal, provide in writing your name, member ID, phone number, the prescription drug for
which benefit coverage has been denied the diagnosis code and treatment codes to which the prescription relates (and the
corresponding explanation for those codes) and any additional information that may be relevant to your appeal. This information
should be mailed to
Mail To:
Address:
EXPRESS SCRIPTS
PO BOX 66587
City, State, Zip:
Attention:
Phone #:
ST. LOUIS, MO 63166-6587
ATTN: ADMINISTRATIVE APPEALS DEPARTMENT
(800) 818-6721
You have the right to review your file and present evidence and testimony as part of your appeal, and the right to a full and fair
impartial review of your claim. A decision regarding your request will be sent to you in writing within 15 days of receipt of your
written request for an appeal. The notice will include information to identify the claim involved, the specific reasons for the decision,
new or additional evidence, if any considered by the plan in relation to your appeal, the plan provisions on which the decision is
based, a description of applicable internal and external review processes and contact information for an office of consumer assistance
or ombudsman (if any) that might be available to assist you with the claims and appeals processes. You have the right to receive, upon
request and at no charge, the information used to review your second level appeal. If new information is received and considered or
relied upon in the review of your second level appeal, such information will be provided to you together with an opportunity to
respond prior to issuance to any final adverse determination of this appeal. The decision made on your second level appeal is final
and binding.
If your second level appeal is denied and you are not satisfied with the decision of the second level appeal or your adverse benefit
determination notice or final adverse benefit determination notice does not contain all of the information required under ERISA, you
also have the right to bring a civil action under section 502(a) of the Employee Retirement Income Security Act of 1974 (ERISA).
In the case of a claim for coverage involving urgent care, you will be notified of the benefit determination within 24 hours of receipt
of the claim. An urgent care claim is any claim for treatment with respect to which the application of the time periods for making
non-urgent care determinations could seriously jeopardize the life or health of the claimant or the ability of the claimant to regain
maximum function, or in the opinion of a physician with knowledge of the claimant’s medical condition, would subject the claimant
to severe pain that cannot be adequately managed. If the claim does not contain sufficient information to determine whether, or to
what extent, benefits are covered, you will be notified within 24 hours after receipt of your claim of the information necessary to
complete the claim. You will then have 48 hours to provide the information and will be notified of the decision within 24 hours of
receipt of the information. If you don’t provide the needed information within the 48-hour period, your claim will be deemed denied.
You have the right to request an urgent appeal of an adverse benefit determination (including a deemed denial) if you request
coverage of a claim that is urgent. Urgent appeal requests may be oral or written. You or your physician may call 800.946.3979or
send a written request to Express Scripts,
Mail To:
EXPRESS SCRIPTS
Address:
City, State, Zip:
Attention:
PO BOX 66587
ST. LOUIS, MO 63166-6587
ATTN: ADMINISTRATIVE APPEALS DEPARTMENT
Phone #:
(800) 818-6721
In the case of an urgent appeal for coverage involving urgent care, you will be notified of the benefit determination within 72 hours of
receipt of the claim. This coverage decision is final and binding. You have the right to receive, upon request and at no charge, the
information used to review your appeal. If new information is received and considered or relied upon in the review of your appeal,
such information will be provided to you together with an opportunity to respond prior to issuance to any final adverse determination
of this appeal. The decision made on your second level appeal is final and binding. You also have the right to bring a civil action
under section 502(a) of Employee Retirement Income Security Act of 1974 (ERISA) if your appeal is denied or your adverse benefit
determination notice or final adverse benefit determination notice does not contain all of the information required under ERISA. You
also have the right to obtain an independent external review. In situations where the timeframe for completion of an internal review
would seriously jeopardize your life or health or your ability to regain maximum function you could have the right to immediately
request an expedited external review, prior to exhausting the internal appeal process, provided you simultaneously file your request
for an internal appeal of the adverse benefit determination. Details about the process to initiate an external review will be described in
any notice of an adverse benefit determination.
For direct claims
Your plan provides for reimbursement of prescriptions when you pay 100% of the prescription price at the time of purchase. This
claim will be processed based on your plan benefit. To request reimbursement you will send your claim to Express Scripts ATTN:
Commercial Claims P.O. Box 2872 Clinton, IA 52733-2872. If your claim is denied, you will receive a written notice within 30 days of
receipt of the claim, as long as all needed information was provided with the claim. You will be notified within this 30 day period if
additional information is needed to process the claim, and a one-time extension not longer than 15 days may be requested and your
claim pended until all information is received. Once notified of the extension, you then have 45 days to provide this information. If
all of the needed information is received within the 45-day time frame and the claim is denied, you will be notified of the denial
within 15 days after the information is received. If you don’t provide the needed information within the 45-day period, your claim
will be deemed denied.
If you are not satisfied with the decision regarding your benefit coverage or your claim is deemed denied, you have the right to appeal
this decision in writing within 180 days of receipt of notice of the initial decision. To initiate an appeal for coverage, you or your
authorized representative (such as your physician), must provide in writing your name, member ID, phone number, the prescription
drug for which benefit coverage has been reduced or denied, the diagnosis code and treatment codes to which the prescription relates
(together with the corresponding explanation for those codes) and any additional information that may be relevant to your appeal.
This information should be mailed to
Mail To :
EXPRESS SCRIPTS
Address:
City, State, Zip:
Attention:
PO BOX 66587
ST. LOUIS, MO 63166-6587
ATTN: ADMINISTRATIVE APPEALS DEPARTMENT
A decision regarding your appeal will be sent to you within 30 days of receipt of your written request. The notice will include
information to identify the claim involved, the specific reasons for the decision, new or additional evidence, if any considered by the
plan in relation to your appeal, the plan provision on which the decision is based, a description of applicable internal and external
review processes and contact information for an office of consumer assistance or ombudsman (if any) that might be available to assist
you with the claims and appeals processes and any additional information needed to perfect your claim. You have the right to receive,
upon request and at no charge, the information used to review your appeal.
If you are not satisfied with the coverage decision made on appeal, you may request in writing, within 90 days of receipt notice of the
decision, a second level appeal. A second level appeal may be initiated by you or your authorized representative (such as your
physician). To initiate a second level appeal, provide in writing your name, member ID, phone number, the prescription drug for
which benefit coverage has been reduced or denied, the diagnosis code and treatment codes to which the prescription relates (and the
corresponding explanation for those codes) and any additional information that may be relevant to our appeal. This information
should be mailed to:
Mail To :
Address:
City, State, Zip:
EXPRESS SCRIPTS
PO BOX 66587
ST. LOUIS, MO 63166-6587
Attention:
ATTN: ADMINISTRATIVE APPEALS DEPARTMENT
You have the right to review your file and present evidence and testimony as part of your appeal, and the right to a full and fair
impartial review of your claim. A decision regarding your request will be sent to you in writing within 30 days of receipt of your
written request for appeal. The notice will include information to identify the claim involved, the specific reasons for the decision,
new or additional evidence, if any considered by the plan in relation to your appeal, the plan provisions on which the decision is
based, a description of applicable internal and external review processes and contact information for an office of consumer assistance
or ombudsman (if any) that might be available to assist you with the claims and appeals processes. You have the right to receive,
upon request and at no charge, the information used to review your second level appeal. If new information is received and
considered or relied upon in the review of your second level appeal, such information will be provided to you together with an
opportunity to respond prior to issuance to any final adverse determination of this appeal. The decision made on your second level
appeal is final and binding.
If your second level appeal is denied and you are not satisfied with the decision of the second level appeal or your adverse benefit
determination notice or final adverse benefit determination notice does not contain all the information required under ERISA, you also
have the right to bring a civil action under section 502(a) of the Employee Retirement Income Security Act of 1974 (ERISA). You
also may have the right to obtain an independent external review. Details about the process to initiate an external review will be
described in any notice of an adverse benefit determination. External reviews are not available for decisions relating to eligibility.