Prescription Drug Program At-a-Glance - High Deductible Health Plans

Transcription

1 Prescription Drug Program At-a-Glance - High Deductible Health Plans Q. What is my prescription drug coverage under State Street s available High Deductible Health Plan options? A. The below table summarizes what you pay and what the plan pays: Drug Category What do you pay? What does the plan pay? Category 1: Preventive and Maintenance Drugs You pay nothing 100% Category 2: All Other Covered Drugs Once you have met your Annual Deductible, you pay the Applicable Coinsurance 100% after you have met the Annual Deductible and paid the Applicable Coinsurance Detailed lists of Preventive and Maintenance Drugs are available with this summary. If your drug is not on the attached list please contact Express Scripts at express-scripts.com/statestreet or to check the drug s coverage level.* Q. What is the Annual Deductible? A. Category 1: Preventive and Maintenance Drugs are not subject to the Annual Deductible and are covered at 100%. Category 2: All Other Covered Drugs are subject to the same deductible that applies for your non-preventive, in-network medical services. The annual deductible is $1,500 individual and $3,000 all other coverage levels for the Cigna 1500 HDHP and $2,500 individual and $5,000 all other coverage levels for the BCBS 2500 HDHP. Don t forget that State Street contributes to your Health Savings Account which can help you pay the annual deductible. Q. What is the Applicable Coinsurance? A. Once you have met your Annual Deductible, the coinsurance you pay depends on the Express Scripts formulary and if you purchase the drug at a participating retail pharmacy for a 30-day or a 90-day supply or through the Express Scripts home-delivery program for a 90-day supply. The tables below and on the following page summarize the Applicable Coinsurance that you pay based on your plan: BCBS 2500 HDHP Express Scripts Formulary Tier Generic Preferred Brand Non-preferred Brand Participating Retail Pharmacy Coinsurance (Category 1 drugs: up to 90-day supply; Category 2 drugs: up to 30-day supply) ($10.00 min and $20.00 max) ($35.00 min and $70.00 max) ($50.00 min and $ max) Home Delivery Coinsurance (90-day supply) ($25.00 min and $50.00 max) ($87.50 min and $ max) ($ min and $ max) _5..

2 Cigna 1500 HDHP Express Scripts Formulary Tier Generic Preferred Brand Non-preferred Brand Participating Retail Pharmacy Coinsurance (Category 1 drugs: up to 90-day supply; Category 2 drugs: up to 30-day supply) ($10.00 min and $20.00 max) ($35.00 min and $70.00 max) ($50.00 min and $ max) Home Delivery Coinsurance (90-day supply) ($25.00 min and $50.00 max) ($87.50 min and $ max) ($ min and $ max) Q. How can I obtain a 90-day supply of a Category 1 medication at a retail pharmacy? A. To take advantage of State Street s 90-day dispensing allowance for Preventive Maintenance medications, you will need to have your physician provide you with a prescription for a 90-day supply of the medication. To obtain a 90-day fill of a Category 1 medication at a retail pharmacy, simply present this 90-day prescription order to your retail pharmacist. To have a 90-day supply of a Category 1 medication delivered directly to your home, and you ve recently obtained a 30-day supply of that medication from a participating network retail pharmacy, just visit express-scripts.com, sign in, and choose which of your current maintenance medications you d like to receive through home delivery by clicking in the box next to the prescription. Or you can call Express Scripts at the toll-free number on your Express Scripts Member ID Card. Express Scripts will then contact your physician s office and request a 90-day prescription so your refills can be mailed directly to you at home _5..

3 2017 Express Scripts Preventive and Maintenance Drug List for State Street Category 1: Preventive and Maintenance Drugs Prescription Drugs: You Make the Choices, We Make it Easy Preventive and Maintenance Prescription Drugs: A Good Choice Prescription drugs that can help keep you from developing a health condition are called preventive and maintenance prescription drugs. They can help you maintain your quality of life and avoid expensive treatment, helping to reduce your overall healthcare costs. If your doctor prescribes a preventive or maintenance prescription drug, you pay nothing, as State Street covers the cost of these medications in full. Is Your Drug a Preventive or Maintenance Prescription Drug? The following is a list of the most commonly prescribed preventive and maintenance drugs. The list is not all-inclusive and does not guarantee coverage. Not all the drugs listed are covered by all prescription-drug benefit programs; check your benefit materials for the specific drugs covered and the coinsurance information for your prescription-drug benefit program. For the member: Generic drugs are listed in lower case letters. Example: atenolol. Generic medications contain the same active ingredients as their corresponding brand-name medications, although they may look different in color or shape. They have been FDA-approved under strict standards. Brand-name drugs are listed in CAPITAL letters. Example: CRESTOR. In addition to using this list, you are encouraged to ask your doctor to prescribe generic drugs whenever appropriate. Some drugs are marked with a symbol *. The symbol * next to a drug signifies subject to nonpreferred status when generic is available throughout the year. For the physician: Please prescribe preferred (Best Buy) products and allow generic substitutions when medically appropriate. Thank you. NOTE: This list does not indicate coverage. You or your doctor may be asked to prove that the drug you're taking is being used for maintenance. This list does not include all conditions that may be maintained with maintenance prescription drugs or all maintenance drugs available. Your plan sponsor believes that these drugs satisfy the requirements for maintenance care as outlined by the U.S. Treasury Department but cannot ensure that the Treasury Department would agree that all of these drugs satisfy the definition of maintenance care. BEST BUY MEDICATIONS The following list of drugs represents the preferred medications under the Preventive and Maintenance care lists. Preferred medications are generic or brand-name drugs available to members at no cost. A afeditab cr AFREZZA albuterol albuterol sulfate alendronate alogliptin alogliptin/metformin altavera alyacen amethia amethyst amiloride hcl amiloride hcl-hctz aminophylline amlodipine-atorvastatin amlodipine besylate amlodipine besylatebenazepril amlodipine-valsartan amlodipine-valsartanhctz ANORO ELLIPTA apri aranelle ARNUITY ELLIPTA aspirin-dipyridamole er atenolol atenolol-chlorthalidone atorvastatin atorvastatin & amlodipine atovaquone-proquanil ATROVENT HFA aviane azurette B balziva benazepril hcl benazepril hcl-hctz BENICAR BENICAR HCT betaxolol hcl bisacodyl bisoprolol fumarate bisoprolol-hctz b-plex BREO ELLIPTA briellyn budeprion sr 150 mg buproban 150 mg bupropion sr 150 mg (associated with smoking cessation only) BYETTA BYVALSON Page 3 C calcium with vitamin D camila camrese candesartan candesartan-hctz captopril captopril-hctz cartia xt caziant cesia CHANTIX CHANTIX STARTING MONTH PAK chloroquine (continued)

4 chlorthalidone cholestyramine cholestyramine light clonidine clopidogrel colestipol hcl COMBIVENT RESPIMAT COREG CR cryselle cvs prenatal vitamin cyclafem D dasetta diaphragm coilspring diaphragm flatspring diltiazem er diltiazem hcl dipyridamole E EFFIENT emoquette enalapril maleate enalapril maleate-hctz enpresse epiflur errin ethedent tab F falmina felodipine er fenofibrate fenofibrate micronized FLUMIST QUAD fluoride drops fluoride fluvastatin folic acid FORADIL FORTEO fosinopril sodium fosinopril-hctz G gemfibrozil gianvi gildess glimepiride glipizide glipizide er glipizide-metformin GLUCAGEN GLUCAGON EMERGENCY KIT glyburide glyburide micronized glyburide-metformin hcl GLYXAMBI guanfacine hcl H heather HUMALOG HUMALOG MIX 50/50 HUMALOG MIX 75/25 HUMULIN HUMULIN 70/30 HUMULIN R hydrochlorothiazide I ibandronate sodium INCRUSE ELLIPTA indapamide introvale INVOKAMET INVOKANA ipratropium bromide ipratropium-albuterol irbesartan irbesartan-hctz iron (drops, liquid) isradipine J jantoven JANUMET JANUVIA JARDIANCE jolessa jolivette junel K kariva kelnor L labetalol hcl LANTUS CARTRIDGE, SOLOSTAR LANTUS VIAL leena lessina levalbuterol inhalation solution LEVEMIR levonest levonorgestrel levonorgestrel-ethinyl estradiol levora lisinopril lisinopril-hctz loryna losartan losartan-hctz lovastatin low-ogestrel ludent fluoride tab lutera M magnesium citrate marlissa mefloquine hcl metformin extended release metformin hcl metformin hcl er metformin-hctz methyclothiazide methyldopa methyldopa-hctz metoprolol succinate metoprolol tartrate metoprolol-hctz MICROGESTIN MIRENA moexipril hcl moexipril-hctz mononessa montelukast multi vita-bets/fl multivit & fluor drops multi-vita bets fl tab multi-vitamin drop multivit-fluor drops multivit-fluor tab multivit-fluoride tab multivit-iron-fl drops myzilra N nadolol nadololbendroflumethiazide nafrinse ped drops necon next choice next choice one dose niacin er nicardipine hcl nifediac cc nifedical xl nifedipine er nora-be norethindrone norethindrone-ethinyl estradiol tab norgestimate-ethinyl estradiol tab nortrel NUCALA O ocella ogestrel Page 4 ONE TOUCH orsythia ORTHO ALL-FLEX DIAPHRAGM P pediatric multi-vit w/fluoride pediatric multi-vit w/fluoride & iron peg 3350-electrolyte philith phluorivit + fe drops phluorivit drops pindolol pioglitazone pioglitazone-glimepiride pioglitazone-metformin polyvitamin-fluor drops polyvit-fluoride drops polyvit-iron-fl drops portia PRADAXA pravastatin sodium prenatal vitamin (generic) previfem PROAIR HFA PROGLYCEM propranolol hcl propranolol hcl w/hctz Q quasense quinapril hcl quinapril-hctz QVAR R raloxifene re multivit-fluor tab reclipsen renaf fluoride tab rena-vite (continued)

5 repaglinide rimantadine hcl RIOMET risendronate 150 mg rosuvastatin S SEREVENT simvastatin sodiphluor drops sodium fluoride drops sodium fluoride tab solia SPIRIVA spironolactone spironolactone-hctz sprintec sronyx STIOLTO RESPIMAT strovite syeda SYMBICORT SYMLIN SYNAGIS SYNJARDY T tamoxifen (oral, liquid) TEKTURNA TEKTURNA HCT telmisartan telmisartan-hctz terbutaline sulfate theophylline tilia fe tolazamide tolbutamide TOUJEO SOLOSTAR trandolapril trandolapril-verapamil TRESIBA triamterene-hctz tri-legest fe trinessa triphluorivit drops triple-vit w-fluor drops tri-previfem tri-sprintec triveen-ten s tri-vit-fluor drops tri-vit-fluor-iron drops trivora TRULICITY V valsartan valsartan-hctz velivet VENTOLIN HFA verapamil er verapamil hcl vestura viorele vitamins a, c, d & fluoride drops W warfarin sodium WELCHOL* wera wide seal diaphragm X XARELTO XIGDUO XR XOLAIR Z zafirlukast zarah zenchent zenchent fe zeosa ZETIA zoledronic acid 5 mg zovia OTHER MAINTENANCE MEDICATIONS The following section lists the nonpreferred medications. These are drugs that are available to the member at a higher cost. A ACCURETIC ACTONEL WITH CALCIUM ADALAT CC ALTOPREV AMARYL AVANDAMET AVANDARYL AVANDIA B BEVESPI AEROSPHERE BONIVA BROVANA C CALAN SR CARDENE SR CARDIZEM CARDIZEM CD chlorpropamide CINQAIR COLESTID COREG CORGARD CORZIDE COUMADIN s CRESTOR D DIABETA DURLAZA ER F FOSAMAX PLUS D G GLUCOPHAGE GLUCOPHAGE XR GLUCOTROL GLUCOTROL XL GLUCOVANCE GLUMETZA GLYNASE GLYSET I INDERAL LA INNOPRAN XL K KAZANO L LESCOL XL LEVATOL LIPOFEN LOFIBRA LOPID LOPRESSOR HCT LOTENSIN HCT LOVAZA M MIACALCIN nasal spray N NESINA nicotine products NICOTROL NORVASC P PLAVIX PRAVACHOL PRECISION QID PRECOSE PROCARDIA XL PROLIA PULMICORT FLEXHALER Q QUESTRAN QUESTRAN LIGHT S SAVAYSA SECTRAL SEEBRI NEOHALER SINGULAIR STARLIX SULAR T TENORETIC TENORMIN TIAZAC ER TOPROL XL TRANDATE TRICOR TRIGLIDE TRUETRACK U UTIBRON NEOHALER V VASERETIC VERELAN VYTORIN X XOPENEX PEDIATRIC INHALATION SOLN Z ZEBETA ZESTORETIC ZIAC ZONTIVITY ZYBAN ZYFLO Page 5