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UPMC Health Plan
University of Pittsburgh
2010 PRESCRIPTION DRUG RIDER
For Faculty & Staff Enrolled in Any University-sponsored Medical Plan
July 1, 2010 - June 30, 2011
TABLE OF CONTENTS PRESCRIPTION DRUG SUPPLY OVERVIEW………………………………………2 RETAIL PRESCRIPTION DRUGS/30-DAY SUPPLY INFORMATION…………….3 MAIL-ORDER PRESCRIPTION DRUGS/90-DAY SUPPLY INFORMATION……. 4 OTHER IMPORTANT FEATURES AND INFORMATION………………………….6
Includes information on Quality Limits, Prior Authorization and Specialty Medications (e.g. Lifestyle and Smoking Cessation Products)
Pursuant to this prescription drug program, you may receive coverage for prescription drugs in the amounts specified in your Prescription Drug Schedule of Benefits when you fill your prescription at a UPMC Health Plan Participating Pharmacy. All capitalized terms in this Rider shall have the same meaning set forth in your Certificate of Coverage. In the event that the terms of this Rider conflict with your Certificate of Coverage, the terms of this Rider control.
PRESCRIPTION DRUG SUPPLY OVERVIEW
To be eligible for benefits, you must purchase your outpatient prescription drugs from a participating pharmacy or through the mail-order program. The chart below shows the copayments and other benefit limitations that apply to your prescription drug program.
o Retail Prescription Drugs
(90-day maximum supply available for 3 copayments)
Available through most retail or independent pharmacies
- Preferred Brand $ 32 per prescription - Non-Preferred Brand $ 64 per prescription
o Mail-Order Prescription Drugs
(90-day maximum supply)
Available through Express Scripts, Falk Clinic Pharmacy or Pitt Student Health Service
- Generic $ 20 per prescription
- Preferred Brand $ 64 per prescription
- Non-Preferred Brand $ 128 per prescription
o Specialty Prescriptions
(30-day maximum supply)
Available through CuraScript $ 64 per prescription
o DEA Class II, III, IV medications
(30-day maximum supply)
You must use 75% of your medication before you
RETAIL PRESCRIPTION DRUGS/30-90DAY SUPPLY INFORMATION
Retail Pharmacy Network The UPMC Health Plan retail pharmacy network provides a national network of approximately 30,000 pharmacies and includes:
o National chain pharmacies, including: CVS Pharmacies, Giant Eagle Pharmacies, Kmart
Pharmacies, Rite Aid Pharmacies, Sam’s Club Pharmacies, Target Pharmacies, Walgreens Pharmacies, and Wal-Mart Pharmacies.
o An extensive network of independent pharmacies such as Pitt Student Health Service Pharmacy
and Falk Clinic Pharmacy along with several regional chain pharmacies.
Generally, retail pharmacies may be utilized for short-term medications, such as medications prescribed to treat illnesses such as a cold, the flu or strep throat. If you use a participating retail pharmacy, the pharmacy will bill UPMC Health Plan directly for your prescription and will ask you to pay any applicable copayment, deductible, or coinsurance. Remember, UPMC Health Plan does not cover prescription drugs obtained from non-participating pharmacies. To locate a participating pharmacy near you, call UPMC Health Plan Member Services at 1-888-499-6885, or visit www.upmchealthplan.com. How to Use Participating Retail Pharmacies
o Take your prescription to a participating retail pharmacy or have your physician call in the
o Verify that your pharmacist has accurate information about you and your covered dependents
o Pay the required copayment or other cost-sharing amount for your prescription.
o Sign for and receive your prescription.
Obtaining a Refill from a Retail Pharmacy You may purchase up to a one-month supply of a prescription drug through a participating pharmacy or a 90 day supply for three copayments. If your physician authorizes a prescription refill, simply bring the prescription bottle or package to the pharmacy or call the pharmacy to obtain your refill. Remember, UPMC Health Plan will not cover refills until you have used 75% of your medication. Please wait until that time to request a refill of your prescription drug. These refill guidelines apply to refills for drugs that are lost, stolen, or destroyed. Replacements for lost, stolen, or destroyed prescriptions will not be covered unless and until you would have met the 75% usage requirement set forth above had the prescription not been lost, stolen, or destroyed.
MAIL-ORDER PRESCRIPTION DRUGS/90-DAY SUPPLY INFORMATION
Mail-Order Pharmacy Services
Generally, long-term maintenance medications may be obtained through the Express Scripts mail-order
pharmacy. Your prescription drug program allows you to receive 90-day supplies for most prescriptions
from the Express Scripts mail-order pharmacy. Certain specialty medications may be limited to a one-
month supply and will generally be dispensed only from Curascript specialty pharmacy.1
You and your doctor can continue to order new prescriptions or refills for specialty and injectable
medications by calling 1-877-787-6279. CuraScript is available Monday through Friday from 8 a.m. to 9
p.m. and Saturday from 9 a.m. to 1 p.m. to assist you. TTY users should call 1-800-899-2114.
When using the mail-order or specialty pharmacy service, you must pay your copayment or other cost-
sharing amount before receiving your medicine through the mail. The copayment applies to each original
prescription or refill (name-brand or generic). You may also obtain 90-day supplies for most prescriptions at the Pitt Student Health Service
Pharmacy by calling 412-383-1850 or Falk Clinic Pharmacy by calling 412-473-7427.
How to Use the Mail-Order Service
o Complete the instructions on the mail-order form. A return envelope is attached to the order form
o Mail the completed order form with your refill slip or new prescription and your payment (check,
money order, or credit card information) to ESI. All major credit cards and debit cards are accepted.
o Contact the mail-order customer service at 1-877-787-6279. The Express Scripts Inc. Customer
Service Center is available 24 hours a day, seven days a week to assist you. TTY users should call 1-800-899-2114.
o You can access the Express Scripts website by logging on to UPMC Health Plan My
OnLine at upmchealthplan.com. You may enter your user ID on the homepage in the member log in box. If you have not accessed My
Health OnLine before, sign up for a personal, secure user ID and password by selecting “New user registration” in the member log in box. Instructions for signing up and accessing My
Health OnLine are available on this page.
o Once you have successfully signed in, Rx Riders can be accessed by selecting the My
and then selecting “Member & Plan details.” You may also access the Express Scripts website by selecting the My
Claims tab and scroll down to the on-line pharmacy box. Here you will have the ability to submit a refill for an existing prescription and check prescription order status.
1 Some common injectable medications may be available at your local retail pharmacy; however, other specialty injectables are available only through CuraScript and may be subject to a one-month supply dispensing limit.
Mail-Order Refills If you need your long-term medication refilled, you can order your refill by phone, mail, or the Internet as set forth in the following table. Be sure to order your refill 2 to 3 weeks before the completion of your current prescription. If you have questions regarding the mail-order service, contact UPMC Health Plan Member Services at 1-888-499-6885 or Express Scripts at 1-877-787-6297.
expiration date), and your phone number.
OTHER IMPORTANT FEATURES AND INFORMATION
The Your Choice
Formulary Your Choice
: The Your Choice
formulary is a four-tier formulary consisting of a Generic tier, a Preferred
brand tier, a Non-Preferred brand tier, and a Specialty drug tier. Brand drugs on the Preferred tier will be
available to members at a lower cost share than non-preferred brands. Formulary high-cost medications
such as biologicals and infusions are covered in the Specialty tier, which may have stricter days’-supply
limitations than the other tiers. Some medications may be subject to utilization management criteria,
including but not limited to prior authorization rules, quantity limits, or step therapy. Selected medications
are not covered with this formulary.
Medications Requiring Prior Authorization
Some medications may require that the physician consult with UPMC Health Plan’s Pharmacy Services
Department the first time he or she prescribes the medication for you. Pharmacy Services must authorize
coverage of those medications before you fill the prescription at the pharmacy. Please see your pharmacy
brochure for a listing of medications that require prior authorization.
UPMC Health Plan has established quantity limits on certain medications to comply with the guidelines
established by Food and Drug Administration (FDA) and to encourage appropriate prescription and use of
these medications. Also, the FDA has approved some medications to be taken once daily in a larger dose
instead of several times a day in a smaller dose. For these medications, your benefit plan covers only the
larger dose per day.
Please note: If the physician orders a strength of a medication that does not exist, the member will be
responsible for one copayment for each of the strengths required to equal the strength of the medication as
prescribed by the physician.
Additional Coverage Information
Your pharmacy benefit plan may cover additional medications and supplies and may exclude medications
that are otherwise listed on your formulary. Additionally, your benefit plan may include specific cost-
sharing provisions for certain types of medications or may offer special deductions in cost-sharing for
participating in certain health management programs. Please read this section carefully to determine
additional coverage information specific to your benefit plan.
Coverage for and/or exclusion of additional medications and supplies
o Your pharmacy benefit plan includes coverage for oral contraceptives.
o Your pharmacy benefit plan includes coverage for the FDA approved erectile dysfunction
(ED) medications Viagra, Cialis, and Levitra at the third tier copayment subject to a utilization management quantity limit of four (4) tablets per 30 days. Cialis 2.5 mg excluded. Periodic adjustments are made to the coverage of existing and new ED drugs, please contact UPMC Member Services at 1-888-499-6885 for the most recent covered drug listing.
o Infertility drug coverage is included at benefit and lifetime limits set forth in the Infertility
rider. Please refer to your Infertility rider for specific infertility coverage information.
Special Provisions for Smoking Cessation
o Products to Treat Nicotine Dependence are covered when prescribed by a physician according
to the manufacturer’s recommended daily dosing as well as the manufacturer’s recommended length of treatment.
o Brand name products for which an FDA-rated equivalent generic product is not available will
be covered at the second tier. Generic products will be covered at the first tier. Brand products that have a FDA-rated equivalent generic version will not be covered.
o The following dosage forms will be covered with the following length of therapy limits:
* Gum up to 12 weeks * Patches up to 12 weeks * Lozenges up to 12 weeks * Nasal spray up to 12 weeks * Zyban up to 12 weeks
* Oral dosage forms up to 12 weeks * Inhalers up to 24 weeks
o You are limited to 2 quit attempts per 365 day period, from the first date of treatment, for the
duration of therapy set forth for all products listed above.
o For more information, or to learn about the support services, please call UPMC Health Plan’s
Health Ready to Quit Line at 1-800-807-0751.
Special Cost-Sharing Provisions for Diabetic Supplies
o Formulary blood glucose monitors do not require a copayment.
o There is no copayment for diabetic supplies when insulin is purchased.
Special Cost-Sharing Provisions for Choosing Brand Name Over Generic Drugs
o According to your formulary, generic drugs will be substituted for all brand name drugs that
o If you choose to purchase the brand name drug instead of the generic equivalent, you must
pay the copayment associated with the brand name drug as well as the retail price difference between the brand name drug and the generic drug.
If your prescribing physician demonstrates to UPMC Health Plan that a brand name drug is Medically Necessary, you will pay only the copayment associated with the non-preferred brand name drug. Creditable Coverage UPMC Health Plan has determined that your prescription drug benefit plan, set forth in this Rider, constitutes creditable coverage in accordance with the applicable regulations established by the Centers for Medicare & Medicaid Services pursuant to the Medicare Prescription Drug Improvement and Modernization Act of 2003.
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