Tri-State Plan SPD >> Prescription Drug Benefits

• At the Pharmacy
• Through Mail Order
• Eligible Drugs
• Excluded Drugs

Your prescription drug benefits are administered by Medco Health Solutions, Inc. (“Medco”). The list of prescription drugs that are covered by your Plan is known as a “formulary.” Your Plan’s formulary includes a wide selection of generic and brand-name medications.

There are two ways to get your prescriptions filled::

At the Pharmacy

• $7.00 if the prescription or refill is filled with a generic drug, or

• $22.00 if it is filled with a brand-name drug.

If your doctor prescribes a formulary brand-name drug and initials the Dispense As Written ("DAW") box when an "A"-rated generic equivalent drug is available, you will have a $22.00 co-payment and you will have to pay the difference in cost between the brand-name drug and the generic drug. Brand-name drugs can be very costly so always ask your doctor to prescribe generic drugs when possible.

Note: you can have your prescription filled at a non-participating pharmacy, but you will have to pay the full cost and then file a claim with Medco to be reimbursed up to the amount Medco would have paid (minus your co-payment). Contact Medco over the phone or on-line to obtain the necessary claim form if you have your prescription filled at a non-participating pharmacy.

Through Mail Order

The mail order program is mandatory for those who take maintenance drugs (medication taken on a regular basis for chronic conditions such as high blood pressure, arthritis, diabetes and asthma). Every calendar year, you and your eligible dependents each have a $2,000 maximum drug benefit available through Medco Mail. Once the Plan has paid $2,000 in any calendar year for your mail order drugs (excluding insulin), you are required to participate in Medco’s maintenance drug program in order to be covered for any additional mail order prescriptions beyond the $2,000 limit. This $2,000 limit does not apply to any acute medications received at the pharmacy or insulin prescriptions received by mail.

• $14.00 for up to a three-month supply per generic prescription or refill, or

• $44.00 for up to a three-month supply per brand name prescription or refill.

If your doctor prescribes a brand-name formulary drug and initials the "DAW" box when an "A"-rated generic equivalent drug is available, you will have to make a $44.00 co-payment and you will have to pay the difference in cost between the brand-name drug and the generic drug.

If you have a chronic condition and you need to take the same medication for more than 30 days, use the Medco mail order service by following these steps.

• When your doctor prescribes a maintenance drug, ask your doctor to write two prescriptions—one for a 30-day supply for you to fill right away at your local retail pharmacy, and a second (for 90 days) to send to the mail order pharmacy for a long-term supply.

• For your first mail service order, fill in the patient profile sections of the Mail Order Pharmacy Order Form, which you can get from the Member Service Center or by calling Medco at 1-800-318-7451. Be sure to complete as much of the information requested as possible. You must provide your unique Medco identification number, name of the person or persons for whom you are sending prescriptions, and the address to whom the medication should be sent. Provide any allergy or history information so that the pharmacist will be aware of any potential drug conflict.

• Complete the Mail Order Pharmacy Order Form for each new prescription.

• Enclose your maintenance drug prescription, the Mail Order Pharmacy Order Form and your payment in the pre-addressed mail service envelope. You must make the necessary co-payment for your mail order or your prescription may not be filled. Your medications are delivered to you at home postage-paid by United Parcel Service or by U.S. mail. Allow 10 to 14 days after the prescription is filled for delivery of your medicine.

• A new order form and envelope will be sent to you with each delivery. These forms are also available from the Member Service Center.

You can order refills by phone (call Medco customer service toll-free at 1-800-318-7451) or from their website (www.medco.com). Have your prescription number and credit card ready when you call or log on.

Please note that certain prescription drugs are not covered or require prior authorization. Your pharmacist can tell you if the prescription drug order you need to have filled is covered by the Plan and if it requires prior authorization. Contact Medco at 1-800-318-7451 before having the prescription filled to ensure that you will receive regular reimbursement for the prescription that you have been given. If you have a prescription filled for a drug that is on the list of those requiring prior authorization, and you fail to contact Medco before having the prescription filled, you may be fully responsible for the cost of the prescription drug.

Refills are not shipped automatically. If you have remaining refills on your original prescription, request your Medco refill three weeks before you need it to avoid running out of medication. You should receive your refill within a week.

Prescriptions for medicines not available through the mail (such as narcotics) will be returned to you. These prescriptions can be filled at the pharmacy for up to a 30-day supply.

Eligible Drugs

The following are covered under the Plan:

• Federal legend prescription drugs

• drugs requiring a prescription under the applicable state law

• insulin, insulin syringes and needles

• diabetic test strips

• oral contraceptives (for participant or spouse; dependents when medically necessary)

• prescription vitamins for infants to 12 months

• pre-natal vitamins, with no co-payment required, provided the Health Services Program is notified within the first 3 months of pregnancy.

Excluded Drugs

The following are not covered under the Plan:

• cough and cold preparations

• non-sedating antihistamines

• gastrointestinal drugs, including H2 blockers and proton pump inhibitors (PPIs)

• dermatological agents like retinoids, keraticolytics, rosacea, emollients and hypopigmentation agents

• drugs for erectile dysfunction

• injectable drugs (except insulin)

• over-the-counter drugs and vitamins (however, certain vitamins are covered for prenatal care – see above for information)

• prescription drugs that require prior authorization and for which you have not received prior authorization

• drugs used in clinical trials or experimental studies

• drugs used for infertility treatment

• birth control devices

• drugs prescribed for cosmetic purposes (see footnote 18 for more information)

• drugs used for weight loss unless you meet the Plan’s medical criteria

• non-formulary drugs, unless your doctor can prove (i.e., clinical documentation; patient’s drug therapy history) to Medco’s satisfaction that the non-formulary drug is necessary (non-formulary drugs are drugs that are not on the Plan’s list of approved drugs and medicines)

• therapeutic devices or appliances, support garments and other non-medical substances

• drugs intended for use in a doctor’s office or another setting other than home use

• prescriptions that an eligible person is entitled to receive without charge under any Workers’ Compensation law, or any municipal, state or Federal program.