Benefit grid template - rx grid 10-10.xls

OUTPATIENT PRESCRIPTION DRUG BENEFIT
Combined Pharmacy and Medical Annual Maximum see Benefit Grid
BENEFIT COPAYMENTS-
Please note that Quantity Limits or Prior Authorization may apply.Refer to your prescription drug formulary guide for additional
information. If the cost of the prescription is less than the applicable copay, you will only be charged the cost of the prescription.
RETAIL PHARMACY-
Up to a 30-day supply for each prescription. A select list of prescription drugs may be eligible for up to a 60-day supply through the tablet-splitting program. (Refer to your prescription drug formulary guide.) *Some preferred generic drugs have a $0 copayTier 2-Preferred Brand Drugs Tier 3-Non-Preferred Brand or Generic Drugs 20% Coinsurance-Diabetic, Ostomy, and Urologic Supplies MAIL ORDER PHARMACY- Up to a 90-day supply for each prescription. Certain prescriptions, including specialty pharmacy
drugs, are not eligible for mail order copays. Refer to your formulary guide for additional information.
*Some preferred generic drugs have a $0 copayTier 2-Preferred Brand Drugs Tier 3-Non-Preferred Brand or Generic Drugs 20% Coinsurance-Diabetic, Ostomy, and Urologic Supplies SPECIALTY PHARMACY-
Up to a 30 day supply for each prescription. Refer to your formulary guide for a list of medications covered under the Specialty Pharmacy Program. Specialty Pharmacy Drugs can be obtained from a contractedSpecialty Pharmacy Provider. COVERED DRUGS & DEVICES
● Compound Drugs-at least one ingredient must be a legend drug● Drugs given or administered in a physician's office or facility that are not otherwise excluded● Drugs used for chemical dependency/alcohol treatment● Immunizations (no copay, deductible or coinsurance applies to childhood immunizations from birth-age 21)● Immunosuppressive Drugs ● Injectable/Infused Drugs, including insulin, epinephrine and glucagons● Legend Drugs-drugs that require a prescription under federal/state laws● Smoking Cessation Drugs-limited to $500 per member per calendar year EXCLUDED DRUGS & DEVICES
● Anti-fungal drugs used for nail fungus● Contraceptive implants, IUDs, diaphragms, contraceptive devices, contraceptive kits, emergency contraception● Convenience or unit dose packaging ● Diabetic supplies other than Bayer or Roche products● Drugs and their equivalents that may be purchased without a prescription; for example, over-the-counter medications are not covered● Drugs obtained at non-contracted pharmacy● Drugs that are not listed on CommunityCare's prescription drug formulary; non-formulary drugs● Drugs used for cosmetic purposes or hair growth● Drugs used for weight management, including anorexiants and bodybuilding drugs● Fertility drugs● Human Growth Hormones and other drugs used to stimulate growth● Investigational/Experimental drugs or used for non-FDA approved indications, including new drug therapies that have not been added to CommunityCare's prescription drug formulary● Lost, damaged or stolen prescriptions● Prescriptions reimbursable under Workers' Compensation or any other government program, or with respect to which the member has no obligation to pay in the absence of insurance● Prescriptions written by non-contracted providers (except for POS/PPO option benefits) Clsd Form. HCM17/HCM17C/HCM17CS/HCM17S-M2 LIMITATIONS: This list is representative and may not be all-inclusive. Changes may be made to this list as determined by the Pharmacy &
Therapeutics Committee.
Quantity Limit
Liquid cough/cold medications (limited to 4 oz. per prescription.) Altabax (30 gm per 30 days)Amerge (limited to 9 tablets per 30 days) Marinol (2.5mg & 10 mg limited to 60 capsules per presciption; 5 Anzemet (limited to 12 tablets per 30 days) mg limited to 50 capsules per prescription) Astelin nasal spray (limited to 2 bottles per 30 days) Maxalt/Maxalt MLT (limited to 9 tablets per 30 days) Astepro nasal spray (limited to 2 bottles per 30 days) Migranal nasal spray (limited to 1 package per 30-day supply) Avelox (limited to 21 tablets per prescription)Avelox ABC (limited to one pack per prescription) Narcotic Analgesics, i.e. Darvocet, Lortab, Percocet, Vicodin Azithromycin (limited to 5 days of therapy/prescription) Butorphanol nasal spray (limited to 2 bottles per 30 days) Omnaris (limited to 2 bottles per 30 days) Celebrex (200 mg limited to 1 capsule per day) Ondansetron (limited to 12 tablets or 100 ml per 30 days) Cesamet (limited to 40 capsules per prescription) Cipro (limited to 28 tablets per prescription) Oral Impotence medications, i.e., Cialis, Levitra, Viagra (limited to Cipro XR (limited to 14 tablets per prescription) Ciprofloxacin (limited to 28 tablets per prescription) Other Impotence medications, i.e., Caverject, Edex, Muse (limited Combunox (limited to 28 tablets per 30 days) Crestor (40mg) (limited to 1 tablet per day) Perforomist (limited to 60 nebs per 30 days) Promethazine syrup (limited to 120 ml per prescription) Duragesic, fentanyl patches (15 patches per 30 days) Proquin XR (limited to 14 tablets per prescription) Emend (limited to 3 capsules per prescription; 40 mg Relpax (limited to 9 tablets per 30 days) Factive (limited to 7 tablets per prescription) Sancuso (limited to 2 patches per 30 days) Fentanyl lollipops (limited to 4 doses per day) Spiriva (limited to 2 inhalers per 30 days) Sumavel (limited to 8 single injections per 30 days) Tamiflu (limited to 10 capsules or 75 ml per prescription) Toradol (limited to 20 tablets per 30 days) Hypnotics, i.e., Ambien Ambien CR,Edular, Lunesta, Rozerem, Tramadol/APAP (limited to 240 tablets per 30-day supply) Sonata, Zolpidem (limited to 1 tablet per day) Travatan/Travatan Z (limited to 2.5 ml per 30 days) Imitrex (limited to 9 tablets, 8 single injections, 1 box of 6 Treximet (limited to 9 tablets per 30 days) Ultracet (limited to 240 tablets per 30 days) Inhalers (limited to 2 inhalers per 30 days;Advair, Advair HFA, Ultram (limited to 240 tablets per 30 days) Foradil, Serevent, Symbicort limited to 1 per 30 days) Veramyst (limited to 2 inhalers per 30 days) Ketek (limited to 20 tablets per prescription) Zithromax (limited to 5 days of therapy per prescription) Ketorolac (limited to 20 tablets per 30-day supply) Zofran (limited to 12 tablets or 100 ml per 30 days) Kytril (limited to 12 tablets or 60 ml per 30 days) Zomig/Zomig ZMT (limited to 9 tablets or 1 box of nasal spray per Levaquin (limited to 14 days of therapy per prescription) Requires Prior Authorization
All Specialty Drugs (see formulary booklet for a list)
Exjade
Gleevec
Nexavar
Revlimid
Sprycel
Sutent
Tarceva
Please consult your pharmacy directory for a list of participating pharmacies in Oklahoma. To find a participating pharmacy outside the state of
Oklahoma, please call 1-877-256-4678 or visit www.express-scripts.com. For all other questions, please call CommunityCare at 877-293-8628.
Copayments for prescription drug benefits are NOT applied to the basic health benefit plan deductible/copayment maximum.
Clsd Form. HCM17/HCM17C/HCM17CS/HCM17S-M2

Source: http://www.oru.edu/faculty_and_staff/employee_benefits/documents/hra_rx_rider.pdf