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Risk & Benefits Management
Prescription Drug Benefits
Most prescriptions are payable at 100% subject to the co-pay amount for each prescription or refill. You pay the co-pay directly to the pharmacy at the time of the purchase.
The maximum medication payable under this program for any one prescription or refill, including insulin, is a 90-day supply. The 90-day supply may be obtained through the mail-order only. Information regarding mail-order is available online at www.medco.com or in the Benefits office.
The maximum supply allowed at a pharmacy (non-mail order) is a 30-day supply.
For a 30-day prescription, 23 days must pass before the prescription can be refilled. For a 90-day prescription, 76 days must pass before a refill may be obtained.
Drugs covered under the Plan must be for the purpose of treating an underlying cause of an illness or injury by relieving pain or preventing serious medical consequences.
Any prescription refilled in excess of the number of refills specified by the physician, or any refill dispensed after one year from the physician’s original order, is not covered by this program.
If you do obtain a prescription from a pharmacy or physician who does not participate in this program, it will be necessary for you to pay the entire charge for the prescription and to file a Direct Reimbursement Claim form (available in the Benefits Office). You must complete the form and include a receipt from your pharmacy or doctor that contains all required information and mail it to the address shown on the back of the form. Your reimbursement will be mailed to you and will be based on the dollar amount called for under this program.
The Prescription Drug Program does not cover drugs not approved by the FDA, experimental drugs, fertility drugs, drugs for sexual dysfunction, dietary drugs or drugs for weight reduction, hair loss, growth hormones, injectable medications (except insulin) unless preauthorized by the Plan, drugs prescribed primarily for cosmetic purposes, or drugs which may be dispensed without a prescription.
Also excluded is medication which is to be taken by or administered, in whole or in part, to an individual while a patient in a licensed hospital, rest home, sanitarium, extended care facility, skilled nursing facility, convalescent hospital, nursing home or similar institution which operates on its premises or allows to be operated on its premises, a facility for dispensing pharmaceuticals.
| Description | Co-Pay FY07 | Co-Pay FY08 | Co-Pay FY09 | Co-Pay FY10 |
| Generic drug | $5.00 | $8.00 | $8.00 | $10.00 |
| Brand name, no generic available | 15.00 | 15.00 | 15.00 | 20.00 |
| Brand name, doctor orders-no substitute | 15.00 | 15.00 | 15.00 | 20.00 |
| Brand name, generic available | 25.00 | 25.00 | 25.00 | 40.00 |
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