Close-Up:
Kevin

Kevin got a severe case of strep throat this winter after returning from location in South Dakota. Unfortunately, he passed it along to his daughter, Paula. Their doctors prescribed antibiotics.

Although Kevin's doctor approved a generic equivalent if one was available, Kevin asked for the brandname drug when he got to the participating pharmacy he typically uses. The pharmacist let him know that there was a $75 price difference between the brand name and the generic, but no difference in quality between the two drugs. Kevin chose the generic and paid only the $10 generic copay instead of paying the generic copay plus the $75 difference in the retail price between the generic and brand name.

Paula's pediatrician wanted her to have an antibiotic that requires only a five-day course of treatment. This antibiotic is currently available as a brand-name drug only, but it does appear as a preferred brand on the PDL. Kevin paid a $10 copay for his generic prescription and a $15 copay for Paula's preferred-brand prescription.

Note: Copays and costs cited in this example are for illustrative purposes only. Your own costs may be different.

What's Covered
The prescription drug program covers the following medications, whether purchased at a retail pharmacy or through the mail-order service:

• Prescription medications and injectable insulin;
• Diabetic supplies when purchased with insulin, including;
  • Needles/syringes/cartridges;
  • Glucometer and/or device;
  • Swabs;
  • Lancets; and
  • Test strips.
    
    When ordered by a physician and purchased separately, these diabetic supplies may be covered under the medical plan;
    
    
• Compounded medication (that is, one prescription combining several ingredients of which at least one ingredient is a prescription drug);
• Oral contraceptives when prescribed by a physician;
• Tretinoin for covered persons under 26 years of age;
• Vitamins that require a prescription; and
• Any other drug that, under state law, may be dispensed only upon written prescription of a physician unless excluded as indicated under "What's Not Covered", below.

What's Not Covered
The following is a partial list of charges that aren't covered by the prescription drug program:

• Any charge for the administration of prescription legend drugs or injectable insulin;
• Any medication, legend or not, that is consumed or administered at the place where it is dispensed, such as chemotherapy;
• Botulinum Toxin A (Botox) (unless approved for certain conditions with case management intervention);
• Botulinum Toxin B (Myobloc) (unless approved for certain conditions with case management intervention);
• Charges you or your dependents aren't required to pay;
• Contraceptives not prescribed by a physician;
• Cosmetic hair removal products;
• Depigmenting agents;
• Drugs labeled: "Caution - limited by federal law to investigational use" or experimental drugs, even though a charge is made to the individual;
• Hair-growth stimulators;
• Immunization agents (except for Synagis), biological sera, blood or blood plasma;
• Items that may be purchased without a written prescription (over the counter);
• Levonorgestel (Norplant)
• Loratadine products;
• Medication that is to be taken by or administered to the individual, in whole or in part, while he/she is a patient in a licensed hospital, nursing home, sanitarium, extended care facility, convalescent hospital, rest home or similar institution that operates a facility for dispensing pharmaceuticals on its premises;
• Non-sedating antihistamines, such as Allegra, except in select cases when your physician provides a letter explaining why the prescribed drug is medically necessary and why the over-the-counter version is not an effective alternative for his/her patient. In this circumstance, the Fund will review the letter and forward it to case management for a final decision;
• Obesity treatment medications;
• Over-the-counter medications, such as Tylenol, Colace, etc.;
• Prescription drugs taken for cosmetic reasons;
• Prescription drugs that aren't medically necessary;
• Prescription drugs that may be obtained without charge under local, state or federal programs, including Workers' Compensation;
• Prescriptions for more than a 30-day supply for retail purchase or a 90-day supply for mail-order (contact the Eligibility Department if you're out of the state or the country for longer than 90 days);
• Proton pump inhibitors (PPIs), such as Nexium, except in select cases when your physician presents compelling written documentation why the over-the-counter version of the drug is not an effective alternative for his/her patient. In this circumstance, the Fund will review the documentation and forward it to case management for a final decision;
• Refilling of a prescription over the amount specified by the physician or dentist, or any refill purchased more than one year from the date of the prescription;
• Testosterone replacement and erectile dysfunction drugs, except in certain cases if your physician provides a letter explaining why the drug is medically necessary. The Fund will review the letter and forward it to case management for a final decision;
• Erectile dysfunction prescription drugs;
• Therapeutic devices or appliances, including hypodermic needles, syringes, support garments and other non-medical substances; and
• Tretinoin, all dosage forms (e.g., Retin-A) for individuals 26 years of age or older. The use of Retin-A as a treatment for photo-aging (wrinkles) isn't covered; coverage for individuals at least 26 years of age may be permitted for other conditions if approved through case management.

Filing A Claim
You need to file a claim whenever you purchase a prescription at a non-participating pharmacy. Mail your receipt to the Administrative Office, and the office will forward it to the outside Claims Administrator for you. You'll be reimbursed directly by the outside Claims Administrator for your out of pocket expense less the applicable copay.