Microsoft word - modified rx 4 drug benefit.doc

Modified IBEW Local 18

RX 4 Drug Benefits


At Anthem Blue Cross, we know that prescription drugs are t
Finding a Participating Pharmacy
the fastest–rising item of your total health care benefits cost. Because our huge pharmacy network includes major Reasons for the spiraling costs of prescription drugs are drugstore chains plus a wide variety of independent varied: a general increase of prescription medication use, pharmacies, it is easy for you to find a participating pharmacy. You can also find a participating pharmacy by an aging population, research and development of new going to our Web site at medications and the expense of direct to consumer advertising. With prescription drug costs increasing at twice An Extensive Network
Besides saving you money, our extensive network of pharmacies
the rate of medical care, we developed ways to contain costs so your copays remain affordable, while maintaining your In California there are over 5,100 retail pharmacies. access to safe, effective prescription drugs. Our Prescription This accounts for nearly 95% of retail pharmacies in the state, Drug Program provides you with choice, flexibility, affordability and access to an extensive network of retail Nationwide there are more than 61,000 chain and independent Getting a Prescription Filled at a Participating Pharmacy
Using a Participating Pharmacy
To get a prescription fil ed, you need only take your prescription to You can substantial y control the cost of your prescription drugs by a participating pharmacy and present your member ID card. The using our extensive network of participating pharmacies. amount you pay for a covered prescription – your copay – wil be Participating pharmacies have agreed to charge a discounted price determined by whether the drug is brand-name or generic or “negotiated rate” and pass along this savings to you. medication and whether it is a preferred or non-preferred medication. Using a Non-Participating Pharmacy
A generic drug contains the same effective ingredients, meets the If you choose to fil your prescription at a non-participating same standards of purity as its brand-name counterpart and pharmacy, your costs wil increase. You wil likely need to pay for typical y costs less. In many situations, you have a choice of fil ing the entire amount of the prescription and then submit a prescription your prescription with a generic medication or a brand-name drug claim form for reimbursement. The pharmacist must sign and complete the appropriate section of the claim form to ensure proper processing of the claim for reimbursement. Our Preferred Drug Program (PDP) encourages the usage of certain, lower-cost, but equal y effective, prescription medications The fol owing chart il ustrates potential increased out-of-pocket (preferred drugs) in place of higher-cost medications (non-preferred expenses for going to a non-participating pharmacy: drugs). The non-preferred list contains medications that require your physician’s approval before they can be substituted for a preferred medication. By al owing this substitution, the PDP helps you better manage the increasing cost of prescription drugs while stil maintaining your access to safe and effective medications. The fol owing chart il ustrates the relation between drug type and your copay amount at a participating pharmacy: Drug Type
Copay Amount
Expense varies based
on the cost of the
You may obtain a prescription drug claim form by cal ing Pharmacy Customer Service at the tol -free number printed on your member ID card or by going to our Web site at Submitting a Claim Form
Supply limits are the proper FDA recommendations for
Check to see that al sections of the claim form are completed and prescription medication dosage coupled with our determination of specific quantity supply limits to prescription medications. Although our standard pharmacy plans offer a 30-day supply for medications at a retail pharmacy, the supply limit can vary based on the medication, dosage and usage prescribed by your physician. For example, the supply limit for antibiotics used to treat an infection Mail Service Prescription Drug Program
(e.g., 14 pil s to be taken twice a day for one week) is different than If you take a prescription drug on a regular basis, you may want to blood pressure medication taken on a routine basis (e.g., 120 pil s take advantage of our mail service program. Ordering your to be taken twice a day for 60 days). By adhering to specified medications by mail is convenient, saves time and depending on supply limits, members are assured of receiving the appropriate your plan design, may even save you money. Besides enjoying the convenience of home delivery, you wil also receive a greater Programs for Member’s Special Health Needs
supply of medications. To fil a prescription through the mail, simply We recognize that some of our members have unique health care complete the Mail Service Prescription form. You may obtain the needs requiring special attention. That’s why we developed form by cal ing Customer Service, at the tol -free number listed on programs exclusively for them. Our additional medical management your ID card or by going to our Web site at programs work in synergy with our pharmacy drug program to help Once you complete the form, simply mail it with your copay and members better manage their health care on an ongoing basis. prescription in the envelope attached to the Mail Service brochure. Diabetic members can receive free glucometers so that they can
Please note that not al medications are available through the Mail effectively and conveniently monitor their glucose levels. Seniors can better monitor their chronic diseases and multiple
medications through our seniors-at-risk program. This program
Out-Of-State Prescription Benefits
reduces the possibility of toxic drug interactions, and curtails
Our national network of participating pharmacies is available to distribution of medications that may adversely affect the senior’s members when outside California. To find a participating pharmacy, a member can check our Web site or cal the tol -free number printed on the ID card. When using a non-participating pharmacy Asthmatic members and their families can take advantage of our
outside of California, the member wil fol ow the same procedures program to better control the frequency and severity of the disease. for using a non-participating pharmacy in California as outlined Members who take multiple prescription medications can take
advantage of our pharmacy utilization management programs that Additional Features That are Part of your Plan
encourage the safe, effective distribution of prescription medications. We have a program that protects the welfare of Prior authorization as the term implies, is similar to prior
members with multiple prescription medications by careful y authorization for medical services. Prior authorization applies to a monitoring their prescription therapy to help reduce the danger of select pool of medications that are often a second line of therapy. To require prior authorization, a drug must meet specific criteria. This criteria is based, among other things, on FDA-approved drug For additional information regarding your prescription drug benefits, indications, targeted populations and the current availability of please cal Pharmacy Customer Service at the effective drug therapies. Prior authorization drugs are not covered tol -free number printed on your member ID card. unless you receive an approval from Anthem Blue Cross. Please refer to your Combined Evidence of Coverage and We distribute instructions on how to obtain prior authorization to Disclosure Form which explains your plan’s Exclusions and physicians and pharmacies so that you may obtain prior Limitations as wel as the ful range of your covered services in authorization for required medications. You may cal Pharmacy Customer Service, at the tol -free number printed on your member ID card, to receive a prior authorization form and/or list of medications requiring prior authorization. Covered Services (outpatient prescriptions only)
Per Member Copay for Each Prescription or Refill
Participating Retail Pharmacy
Mail Service
Non-participating Pharmacies
Member pays the above copay plus: Supply Limits1
30-day supply; 60-day supply for federal y classified (participating and non-participating) Schedule II attention deficit disorder drugs that require a triplicate prescription form, but require a double copay; 6 tablets or units/30-day period for impotence and/or sexual dysfunction drugs (available only at retail pharmacies) 1Supply limits for certain drugs may be different. Please refer to the Evidence of Coverage and Disclosure form (EOC) for complete information. The Prescription Drug Benefit covers the following:
Outpatient prescription drugs and medications. Formulas prescribed by a physician for the treatment of phenylketonuria. These formulas are subject to the copay for brand name drugs. Insulin. Syringes when dispensed for use with insulin and other self-injectable drugs or medications. Prescription oral contraceptives; contraceptive diaphragms. Contraceptive diaphragms are limited to one per year and are subject to the Injectable drugs which are self-administered by the subcutaneous route (under the skin) by the patient or family member. Drugs that have Food and Drug Administration (FDA) labeling for self-administration Al compound prescription drugs that contain at least one covered prescription ingredient. Diabetic supplies (i.e., test strips and lancets). Prescription drugs for treatment of impotence and/or sexual dysfunction are limited to organic (non-psychological) causes. Prescription drug copays are separate from the medical copays of the medical plan and are not applied toward the Annual
Out-of-Pocket Maximums.

Prescription Drug Exclusions & Limitations
Immunizing agents, biological sera, blood, blood products or blood plasma
Drugs which have not been approved for general use by the State of California Department of Hypodermic syringes &/or needles, except when dispensed for use with insulin & other self- Health or the Food and Drug Administration Drugs & medications used to induce spontaneous & non-spontaneous abortions Drugs used primarily for cosmetic purposes (e.g., Retin-A for wrinkles) Drugs & medications dispensed or administered in an outpatient setting, including outpatient Drugs used primarily to treat infertility (including, but not limited to, Clomid, Pergonal and Metrodin) hospital facilities and physicians’ offices Anorexiants and drugs used for weight loss, except when used to treat morbid obesity (e.g., diet Professional charges in connection with administering, injecting or dispensing drugs Drugs & medications that may be obtained without a physician’s written prescription, except insulin Al ergy desensitization products or al ergy serum Drugs & medications dispensed by or while confined in a hospital, skil ed nursing facility, rest home, Infusion drugs, except drugs that are self-administered subcutaneously sanatorium, convalescent hospital or similar facility Select classes of drugs where non-preferred medications, which have therapeutic alternatives, have Durable medical equipment, devices, appliances & supplies, even if prescribed by a physician, shown no benefit regarding efficacy or side effect over preferred drugs; however, this wil not apply except contraceptive diaphragms, as specified as covered in the EOC if the prescriber denotes “dispense as written” or “do not substitute” Services or supplies for which the member is not charged Herbal, nutritional and dietary supplements except for formulas for the treatment of phenylketonuria. Prescription drugs with a non-prescription (over-the-counter) chemical and dose equivalent except Drugs labeled “Caution, Limited by Federal Law to Investigational Use,” or experimental drugs. Third Party Liability
Drugs or medications prescribed for experimental indications Anthem Blue Cross is entitled to reimbursement of benefits paid if the member recovers damages Any expense for a drug or medication incurred in excess of (a) the Drug Limited Fee Schedule for drugs dispensed by non-participating pharmacies; or (b) the prescription drug negotiated rate for drugs dispensed by participating pharmacies or through the mail service program Anthem Blue Cross is the trade name of Blue Cross of California. Independent Licensee of
the Blue Cross Association. ® ANTHEM is a registered trademark. ® The Blue Cross name
and symbol are registered marks of the Blue Cross Association.



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