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  Section 5(f). Prescription drug benefits

What's in this Section:
•   Who can write your prescriptions
•   Where you can obtain them
•   We use a formulary
•   These are the dispensing limitations
•   Why use generic drugs
 •   Patient Safety
•   To claim benefits
•   Coordinating with other drug coverage
•   Covered medications and supplies

Important things you should keep in mind about these benefits:
  • We cover prescribed drugs and medications, as described in the chart beginning on page 55.


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  • Please remember that all benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.


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  • The calendar year deductible does not apply to prescription drugs.


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  • The non-PPO benefits are the regular benefits of this Plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.


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  • Certain prescription drugs and supplies require prior approval by SAMBA and/or Medco.


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  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

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There are important features you should be aware of. These include:
  • Who can write your prescription. A licensed physician or other covered provider acting within the scope of their license must write the prescription.


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  • Where you can obtain them. You may fill the prescription at a participating Plan network pharmacy, a non-network pharmacy, or by mail. To receive the Plans maximum benefit, you must fill the prescription at a plan pharmacy, or by mail for a maintenance medication.


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  • We use a formulary. The formulary identifies preferred name brand drugs that have been selected for their clinical effectiveness and opportunities to help contain your and SAMBA's costs. Our formulary applies to drugs received from a network retail pharmacy or our mail order program. Your copayment or coinsurance amounts are less for drugs listed on the formulary than those that are not.

    Our payment levels are categorized as:

    Level I: generic drugs
    Level II: formulary or preferred name brand drugs
    Level III: non-formulary or non-preferred name brand drugs

    You may look up the formulary status of medications online at www.medco.com or call 1-800/283-3478.


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  • These are the dispensing limitations.
    • High Option Retail: You may purchase up to a 30-day supply with unlimited refills of covered drugs or supplies through the Medco Health system available at most pharmacies. Call toll-free 1-800/283-3478 to locate a Plan network pharmacy in your area.


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    • Standard Option Retail: You may only obtain a 30-day supply and one refill at a Plan network pharmacy. This limit does not apply to medications not available through the mail order program. Call 1-800/283-3478 to locate a network pharmacy in your area.


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    • High Option and Standard Option Mail Order: You may purchase up to a 90-day supply of covered drugs or supplies through the mail order program. You order your prescription or refill by mail from Medco By Mail. Medco By Mail will fill your prescription.


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    Note: Not all drugs may be available through the mail order program. Any drug which cannot be dispensed in accordance with Medco By Mail pharmacy's dispensing protocols or which requires special record-keeping procedures may be excluded. However, these excluded drugs are covered under the retail prescription drug program.

    If your physician prescribes a medication that will be taken over an extended period of time, you should request two prescriptions one to be used for the participating Plan network pharmacy and the other for Medco By Mail. You may obtain up to a 30-day supply right away through the prescription card program, and up to a 90-day supply from Medco By Mail. In most cases, refills cannot be obtained until 75% of the prescription has been used. Call us or visit our web site if you have any questions about dispensing limits.

    The Plan will authorize up to a 90-day supply of medication(s) if you should be called to active military duty or a 30-day supply to meet your needs in time of a national emergency.

    Benefits for all prescription drugs will be determined based on the fill date of the prescription.

    A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you receive a name brand drug when a Federally-approved generic drug is available, you have to pay the difference in cost between the name brand drug and the generic.


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  • Why use generic drugs? Generic drugs are lower-priced drugs that are the therapeutic equivalent to more expensive name brand drugs. They must contain the same active ingredients and must be equivalent in strength and dosage to the original name brand product. Generics cost less than the equivalent name brand product. The U.S. Food and Drug Administration sets quality standards for generic drugs to ensure that these drugs meet the same standards of quality and strength as name brand drugs.

    You and your doctor have the option to request a name brand drug even if a generic equivalent is available. However, you will be responsible for the difference in cost between the name brand drug and the generic even when the physician indicates dispense as written (DAW). Using the most cost effective medication saves money.


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  • Patient Safety

    SAMBA has several programs to promote patient safety. These programs work to ensure that safe and appropriate quantities of medication are being dispensed. The result is improved care and safety for our members. Patient safety programs include:
    • Pharmacy utilization: Used to identify and restrict over-utilization or inappropriate use of medications that treat certain conditions.


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    • Prior authorization: Prior authorization must be obtained for certain prescription drugs and supplies to assess appropriate therapy and drug dosage before providing benefits.


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    Contact Medco Health at 1-800/753-2851 for additional information regarding the Patient Safety programs.


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  • To claim benefits.
    • From a pharmacy - When you purchase medication from a network pharmacy use your SAMBA/Medco Health Identification Card. In most cases, you simply present the card, together with the prescription, to the pharmacist; the claim is automatically filed through the Medco Health system.

      If you do not use your identification card when purchasing your medication, or you use a non-network pharmacy, you must complete a direct reimbursement claim form to claim benefits. You may obtain these forms by calling Medco Health toll-free at 1-800/283-3478. Service is available 7 days a week, 24 hours a day. Follow the instructions on the form and mail it to:
      Medco Health Solutions, Inc.
      P. O. Box 14711
      Lexington, KY 40512

      Note: Reimbursement will be limited to SAMBA's cost had you used a participating pharmacy minus the copayments described on page 55.


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    • By mail - The Plan will send you information on Medco By Mail:
      1. Ask your doctor to give you a new prescription for up to a 90-day supply of your regular medication plus refills, if appropriate;


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      2. Complete the patient profile questionnaire the first time you order under the program; and


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      3. Complete a mail order envelope, enclose your prescriptions, and mail them along with the required copayment for each prescription or refill to:
        Medco
        P. O. Box 650022
        Dallas, TX 75265-0022

      You must pay your share of the cost by check, money order, VISA, Discover, or MasterCard (complete the space provided on the order envelope to use your charge card).

      You will receive forms for refills and future prescription orders each time you receive drugs or supplies under the Program. In the meantime, if you have any questions about a particular drug or a prescription, and to request your first order forms, you may call 1-800/283-3478 toll-free. Customer service is available 7 days a week, 24 hours a day (except Thanksgiving and Christmas). You may also download order forms from www.medco.com.

      Under the High Option, if Medicare Part B or Part D is your primary payer, the Plan will reduce the required copayment amount for purchases made through Medco By Mail. See page 55 for copayment amounts.

      Note: As at your local pharmacy, if you request a name brand prescription when a generic equivalent is available, you will be responsible for the difference in price between the name brand drug and its generic equivalent.

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  • Coordinating with other drug coverage.

    If you have prescription drug coverage through another insurance carrier, and SAMBA is secondary, follow the procedures outlined below.

    When another insurance carrier is primary you should use that carrier's prescription drug benefits.

    However, if you elect to use Medco By Mail, you will be billed directly for the full discounted cost of the covered medication. Pay Medco By Mail the amount billed and submit the bill to your primary insurance carrier. After their consideration submit the claim and the explanation of benefits (EOB) directly to the Medco office at:
    Medco Health Solutions, Inc.
    P. O. Box 14711
    Lexington, KY 40512


    Should you elect to use a retail pharmacy, follow your primary insurance carrier's instructions on how to file a claim. After their consideration, submit the claim and the explanation of benefits (EOB) directly to the Medco office at:
    Medco Health Solutions, Inc.
    P. O. Box 14711
    Lexington, KY 40512

Benefit Description You Pay
Covered medications and supplies High Option Standard Option
Each new enrollee will receive a description of our prescription drug program, a prescription drug identification card, a mail order form/patient profile, and a preaddressed reply envelope.

You may purchase the following medications and supplies prescribed by a physician from either a pharmacy or by mail:
  • Drugs that by Federal law of the United States require a doctors prescription for purchase


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  • Insulin


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  • Needles and syringes for the administration of covered medications, such as insulin


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  • Contraceptive drugs and devices


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  • Growth hormone therapy (GHT), if preauthorized

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Note: The Medicare level of benefits applies only when Medicare Part B or Part D is your primary payer.

Note: Retail copayments will apply to prescription drugs billed by a skilled nursing facility, nursing home or extended care facility.

Note: Under the Standard Option there is a $5,000 per person, per calendar year catastrophic protection limit on your out-of-pocket copayment and coinsurance expenses for prescription medications obtained from a Network retail pharmacy or through our Mail Order program. This limit does not apply to drugs obtained from any other source.
 Copayments per prescription or refill are:

Retail:
  • $10 generic


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  • $30 preferred name brand


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  • $45 non-preferred name brand

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Retail Medicare:
  • $10 generic


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  • $25 preferred name brand


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  • $40 non-preferred name brand

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Note: For retail purchases made at a non-Network pharmacy, you pay the same per prescription copayments listed above, plus the difference in cost had you used a participating Plan network pharmacy.

Network Mail Order:
  • $10 generic


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  • $50 preferred name brand


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  • $65 non-preferred name brand

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Network Mail Order Medicare:
  • $10 generic


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  • $30 preferred name brand


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  • $50 non-preferred name brand

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Note: For generic and name brand drug purchases, if the cost of your prescription is less than your cost-sharing amount listed above, you pay only the cost of your prescription.

If there is no generic equivalent available, you will have to pay the name brand copayment.
 Copayments per prescription or refill are:

Retail:
  • $10 generic


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  • 25% ($30 minimum/$60 maximum for each purchase) preferred name brand


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  • 35% ($45minimum/$90 maximum for each purchase) non-preferred name brand

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Note: For retail purchases made at a non-Network pharmacy, you pay the same per prescription copayments listed above, plus the difference in cost had you used a participating Plan network pharmacy.

Retail purchases are limited to the initial fill (not to exceed a 30-day supply) and one refill.

Network Mail Order:
  • $20 generic


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  • 25% of the Plan allowance ($50 minimum/$100 maximum for each purchase) preferred name brand


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  • 35% of the Plan allowance ($65 minimum/$120 maximum for each purchase) non-preferred name brand

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Note: Medicare enrollees pay the same prescription drug copayments as listed above.

Note: For generic and name brand drug purchases, if the cost of your prescription is less than your cost-sharing amount listed above, you pay only the cost of your prescription.

If there is no generic equivalent available, you will have to pay the name brand copayment.
Not covered:
  • Drugs and supplies for cosmetic purposes, e.g., Retin A, Minoxidil, Rogaine


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  • Vitamins (except injectable B-12)


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  • Over-the-counter nutritional supplements and medical foods


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  • Nonprescription medicines (over-the-counter medication)


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  • The difference in cost between the name brand drug and the generic substitute when a generic equivalent is available


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  • Drugs for sexual dysfunction, e.g., Viagra, Muse, Caverject, etc.


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  • Cost of fertility drugs

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Note: Drugs to aid in smoking cessation are covered only under Educational classes and programs (Section 5(a)).
 All charges All charges



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