Hbcsd.k12.ca.us

SISC 90 A $20 Anthem Classic PPO
PPO
In addition to dollar and percentage copays, members are responsible for deductibles, as described below. Please review the B
deductible information to know if a deductible applies to a specific covered service. Certain Covered Services have maximum visit e
and/or day limits per year. The number of visits and/or days allowed for these services wil begin accumulating on the first visit and/or n
day, regardless of whether your Deductible has been met. Members are also responsible for all costs over the plan maximums. Plan e
maximums and other important information appear in italics. Benefits are subject to all terms, conditions, limitations, and exclusions of the fits
Explanation of Covered Expense
Plan payments are based on covered expense, which is the lesser of the charges bil ed by the provider or the following: PPO Providers—PPO negotiated rates. Members are not responsible for the dif erence between the provider’s usual charges & the Non-PPO Providers—For non-emergency services, the scheduled amount. For emergency services, same as other health care providers Other Health Care Providers (includes those not represented in the PPO provider network)—The customary & reasonable charge for professional services or the reasonable charge for institutional services.
When using Non-PPO and Other Health Care Providers, members are responsible for any difference between the
covered expense & actual charges, as wel as any deductible & percentage copay.
Calendar year deductible for al providers
Co-pay for emergency room services
$100/visit (waived if admitted directly from ER) Annual Out-of-Pocket Maximums
The following do not apply to out-of-pocket maximums: deductibles listed above; non-covered expense, and co-pays. After a member reaches the out-of-pocket maximum, the member remains responsible for deductibles listed above; for non-PPO providers & other health care providers, costs in excess of the covered expense; amounts related to a transplant unrelated donor search, and office visit co-pays.
Lifetime Maximum
Covered Services
Non-PPO: Per
Member Copay
Member Copay1
Hospital Medical Services (subject to utilization review
for inpatient services; waived for emergency admissions)  Semi-private room, meals & special diets,  Outpatient medical care, surgical services & supplies (hospital care other than emergency room care)  Single Hip or Knee Joint Replacement Surgery – 10% 0% up to $30,000 per surgery. Travel expense when member’s home is 50 miles or more from a low cost facility. ($3000 maximum travel benefit per surgery)
Ambulatory Surgical Centers
 Outpatient surgery, services & supplies Hemodialysis
 Outpatient hemodialysis services & supplies Skilled Nursing Facility (subject to utilization review)
 Semi-private room, services & supplies (limited to 100 days/calendar year) Hospice Care 0% 0%
 Inpatient or outpatient services; family bereavement services (deductible waived) 1The percentage copay for non-emergency services from non-Anthem Blue Cross PPO providers is based on the scheduled amount. Member is responsible for all charges exceeding the scheduled amount. 2 These providers are not represented in the Anthem Blue Cross PPO network. Covered Services
Non-PPO: Per
Member Copay
Member Copay1
Home Health Care (subject to utilization review)
 Services & supplies from a home health agency (limited to 100 visits/calendar year, one visit by a home health aide equals four hours or less; not covered while member receives hospice care) Home Infusion Therapy (subject to utilization review)
 Includes medication, ancil ary services & supplies; caregiver training & visits by provider to monitor therapy; durable medical equipment; lab services Physician Medical Services
 Hospital & skilled nursing facility visits  Surgeon & surgical assistant; anesthesiologist or anesthetist Diagnostic X-ray & Lab
 MRI, CT scan, PET scan & nuclear cardiac scan  Other diagnostic x-ray & lab Physical Exams for Members (Adults & Children- all ages)
 Routine physical exams, immunizations, diagnostic X-ray & lab for routine physical exam Adult Preventive Services (including mammograms,
Pap smears, prostate cancer screenings & colorectal cancer screenings) Physical Therapy, Physical Medicine & Occupational
Therapy, including Chiropractic Services (subject to medical necessity
review administered by American Specialty Health - ASH) Speech Therapy
Acupuncture
 Services for the treatment of disease, il ness or injury (limited 12 visits/calendar year) Temporomandibular Joint Disorders
 Splint therapy & surgical treatment Pregnancy & Maternity Care
 Prescription drug for elective abortion (mifepristone) Normal delivery, cesarean section, complications of pregnancy & abortion (newborn routine nursery care covered when natural mother is subscriber or spouse/domestic partner)  Inpatient physician services 1 The percentage copay for non-emergency services from non-Anthem Blue Cross PPO providers is based on the scheduled amount. Member is responsible for all charges 2 The dollar copay applies only to the visit itself. An additional 10% copay applies for any services performed in office (i.e., X-ray, lab, surgery), after any applicable deductible. 3 Acupuncture services can be performed by a certified acupuncturist (C.A.), a doctor of medicine (M.D.), a doctor of osteopathy (D.O.), a podiatrist (D.P.M.), Covered Services
Non-PPO: Per
Member Copay
Member Copay1
Organ & Tissue Transplants (subject to utilization review;
specified organ transplants covered only when performed at Centers of Medical Excellence [CME])  Inpatient services provided in connection with non-investigative organ or tissue transplants  Transplant travel expense for an authorized, (recipient & companion transportation limited to  Unrelated donor search, limited to $30,000 per transplant
Bariatric Surgery (subject to utilization review; medically
necessary surgery for weight loss, only for morbid obesity covered only when performed at Centers of Medical Excellence [CME])  Inpatient services provided in connection with medically necessary surgery for weight loss, only for morbid obesity  Bariatric travel expense when member’s home is 50 miles or more from the nearest Bariatric CME ($3,000 maximum travel benefit per surgery) Diabetes Education Programs (requires physician supervision)
 Teach members & their families about the disease process, the daily management of diabetic therapy & Prosthetic Devices
 Coverage for breast prostheses; prosthetic devices to restore a method of speaking; surgical implants; artificial limbs or eyes; the first pair of contact lenses or eyeglasses when required as a result of eye surgery; & therapeutic shoes & inserts for members with diabetes Durable Medical Equipment
 Rental or purchase of DME including hearing aids, Hearing Aid
 Supplies and equipment (limited to $700 per 24 months) 10% Related Outpatient Medical Services & Supplies
 Ground or air ambulance transportation, services  Blood transfusions, blood processing & the cost of  Autologous blood (self-donated blood collection, testing, processing & storage for planned surgery) 1 The percentage copay for non-emergency services from non-Anthem Blue Cross PPO providers is based on the scheduled amount. Member is responsible for all charges 2 These providers are not represented in the Anthem Blue Cross PPO network. Covered Services
Non-PPO: Per
Member Copay
Member Copay1
Specialty Pharmacy Drugs (utilization review may be required)
 Specialty pharmacy drugs fil ed through the specialty pharmacy program (limited to 30-day supply; not covered if benefits are provided through prescription drug benefits, If member does not get specialty pharmacy drugs from the
specialty pharmacy program, member wil not receive any
specialty pharmacy drug benefits under this plan, unless the
member qualifies for an exception as specified in the EOC.
Emergency Care
 Emergency room services & supplies  Inpatient hospital services & supplies Mental or Nervous Disorders and Substance Abuse
 Facility-based care (subject to utilization review;  Facility-based care (subject to utilization review; (pre-service review required after the 12th visit) 1 The percentage copay for non-emergency services from non-Anthem Blue Cross PPO providers is based on the scheduled amount. Member is responsible for all charges 2 10% copay if member or non-PPO physician obtains drug from Specialty Pharmacy Program; otherwise, not covered. 3 The allowable rate for emergency within 48 hours is based on a reasonable charge, not the scheduled amount. This Summary of Benefits is a brief review of benefits. Once enrol ed, members wil receive a Combined Evidence of Coverage and
Disclosure Form, which explains the exclusions and limitations, as well as the ful range of covered services of the plan,
in detail.
Classic PPO Exclusions and Limitations
Not Medically Necessary. Services or supplies that are not medically necessary, as defined.
Sterilization Reversal.
Experimental or Investigative. Any experimental or investigative procedure or medication.
Infertility Treatment. Any services or supplies furnished in connection with the diagnosis and
But, if member is denied benefits because it is determined that the requested treatment treatment of infertility, including, but not limited to diagnostic tests, medication, surgery, artificial is experimental or investigative, the member may request an independent medical review, insemination, in vitro fertilization, sterilization reversal and gamete intrafallopian transfer. as described in the Evidence of Coverage (EOC). Surrogate Mother Services. For any services or supplies provided to a person not covered under
Crime or Nuclear Energy. Conditions that result from (1) the member’s commission of or attempt
the plan in connection with a surrogate pregnancy (including, but not limited to, the bearing of a to commit a felony, as long as any injuries are not a result of a medical condition or an act of child by another woman for an infertile couple). domestic violence; or (2) any release of nuclear energy, whether or not the result of war, when Orthopedic Supplies. Orthopedic supplies, orthopedic shoes (other than shoes joined to braces),
government funds are available for the treatment of il ness or injury arising from the release or non-custom molded and cast shoe inserts, except for therapeutic shoes and inserts for the prevention and treatment of diabetes-related feet complications as specified as covered in the EOC. Not Covered. Services received before the member’s effective date. Services received
Air Conditioners. Air purifiers, air conditioners or humidifiers.
after the member’s coverage ends, except as specified as covered in the EOC. Custodial Care or Rest Cures. Inpatient room and board charges in connection with a hospital
Excess Amounts. Any amounts in excess of covered expense or the lifetime maximum.
stay primarily for environmental change or physical therapy. Services provided by a rest home, Work-Related. Work-related conditions if benefits are recovered or can be recovered, either by
a home for the aged, a nursing home or any similar facility. Services provided by a skil ed nursing adjudication, settlement or otherwise, under any workers’ compensation, employer’s liability law facility or custodial care or rest cures, except as specified as covered in the EOC. or occupational disease law, whether or not the member claims those benefits. If there is a dispute Chronic Pain. Treatment of chronic pain, except as specified as covered in the EOC.
of substantial uncertainty as to whether benefits may be recovered for those conditions pursuant to workers’ compensation, we wil provide the benefits of this plan for such conditions, subject to a Health Club Memberships. Health club memberships, exercise equipment, charges from a
right of recovery and reimbursement under California Labor Code Section 4903, as specified as physical fitness instructor or personal trainer, or any other charges for activities, equipment or facilities used for developing or maintaining physical fitness, even if ordered by a physician. This Government Treatment. Any services the member actually received that were provided by a local, exclusion also applies to health spas.
state or federal government agency, except when payment under this plan is expressly required by Personal Items. Any supplies for comfort, hygiene or beautification.
federal or state law. We wil not cover payment for these services if the member is not required to Education or Counseling. Educational services or nutritional counseling, except as specified
pay for them or they are given to the member for free. as covered in the EOC. This exclusion does not apply to counseling for the treatment of anorexia Services of Relatives. Professional services received from a person living in the member’s
home or who is related to the member by blood or marriage, except as specified as covered Food or Dietary Supplements. Nutritional and/or dietary supplements, except as provided in this
plan or as required by law. This exclusion includes, but is not limited to, those nutritional formulas Voluntary Payment. Services for which the member has no legal obligation to pay, or for which
and dietary supplements that can be purchased over the counter, which by law do not requirement no charge would be made in the absence of insurance coverage or other health plan coverage, either a writ en prescription or dispensing by a licensed pharmacist. except services received at a non-governmental charitable research hospital. Such a hospital must Telephone and Facsimile Machine Consultations. Consultations provided by telephone
1. it must be internationally known as being devoted mainly to medical research; Routine Exams or Tests. Routine physical exams or tests which do not directly treat an actual
2. at least 10% of its yearly budget must be spent on research not directly related to il ness, injury or condition, including those required by employment or government authority, except as specified as covered in the EOC. 3. at least one-third of its gross income must come from donations or grants other than gifts Acupuncture. Acupuncture treatment, except as specified as covered in the EOC. Acupressure
or massage to control pain, treat il ness or promote health by applying pressure to one or more specific areas of the body based on dermatomes or acupuncture points. it must accept patients who are unable to pay; and Eye Surgery for Refractive Defects. Any eye surgery solely or primarily for the purpose of
two-thirds of its patients must have conditions directly related to the hospital’s research. correcting refractive defects of the eye such as nearsightedness (myopia) and/or astigmatism. Not Specifically Listed. Services not specifically listed in the plan as covered services.
Contact lenses and eyeglasses required as a result of this surgery. Private Contracts. Services or supplies provided pursuant to a private contract between the
Physical Therapy or Physical Medicine. Services of a physician for physical therapy or physical
member and a provider, for which reimbursement under Medicare program is prohibited, as medicine, except when provided during a covered inpatient confinement or as specified specified in Section 1802 (42 U.S.C. 1395a) of Title XVI I of the Social Security Act. Inpatient Diagnostic Tests. Inpatient room and board charges in connection with a hospital stay
Outpatient Prescription Drugs and Medications. Outpatient prescription drugs or medications
primarily for diagnostic tests which could have been performed safely on an outpatient basis. and insulin, except as specified as covered in the EOC. Any non-prescription, over-the-counter Mental or Nervous Disorders. Academic or educational testing, counseling, and remediation.
patent or proprietary drug or medicine. Cosmetics, health or beauty aids. Mental or nervous disorders or substance abuse, including rehabilitative care in relation to these Specialty Pharmacy Drugs. Specialty pharmacy drugs that must be obtained from the specialty
conditions, except as specified as covered in the EOC. pharmacy program, but, which are obtained from a retail pharmacy, are not covered by this plan. Nicotine Use. Smoking cessation programs or treatment of nicotine or tobacco use.
Member wil have to pay the ful cost of the specialty pharmacy drugs obtained from a retail
pharmacy that should have been obtained from the specialty pharmacy program.
Orthodontia. Braces, other orthodontic appliances or orthodontic services.
Contraceptive Devices. Contraceptive devices prescribed for birth control except as specified
Dental Services or Supplies. Dental plates, bridges, crowns, caps or other dental prostheses,
dental implants, dental services, extraction of teeth, treatment to the teeth or gums, or treatment to Diabetic Supplies. Prescription and non-prescription diabetic supplies except as specified
or for any disorders for the temporomandibular (jaw) joint, except as specified as covered in the EOC. Cosmetic dental surgery or other dental services for beautification. Private Duty Nursing. Inpatient or outpatient services of a private duty nurse.
Hearing Aids or Tests. Hearing aids and routine hearing tests, except as specified as covered
Lifestyle Programs. Programs to alter one’s lifestyle which may include but are not limited to diet,
exercise, imagery or nutrition. This exclusion wil not apply to cardiac rehabilitation programs Optometric Services or Supplies. Optometric services, eye exercises including orthoptics.
Routine eye exams and routine eye refractions, as specified as covered in the EOC. Eyeglasses or contact lenses, except as specified as covered in the EOC. Third Party Liability — Anthem Blue Cross is entitled to reimbursement of benefits paid if the
Outpatient Occupational Therapy. Outpatient occupational therapy, except by a home health
member recovers damages from a legally liable third party. agency, hospice, or home infusion therapy provider, as specified as covered in the EOC. Coordination of Benefits — The benefits of this plan may be reduced if the member has any other
Outpatient Speech Therapy. Outpatient speech therapy, except as specified as covered
group health or dental coverage so that the services received from all group coverages do not Cosmetic Surgery. Cosmetic surgery or other services performed solely for beautification or to
alter or reshape normal (including aged) structures or tissues of the body to improve appearance. Anthem Blue Cross is the trade name of Blue Cross of California. Independent Licensee of
This exclusion does not apply to reconstructive surgery (that is, surgery performed to correct the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance
deformities caused by congenital or developmental abnormalities, il ness, or injury for the purpose Companies, Inc. The Blue Cross name and symbol are registered marks of the
of improving bodily function or symptomatology or to create a normal appearance), including Blue Cross Association.
surgery performed to restore symmetry following mastectomy. Cosmetic surgery does not become reconstructive surgery because of psychological or psychiatric reasons.
Commercial Weight Loss Programs. Weight loss programs, whether or not they are pursued
under medical or physician supervision, unless specifically listed as covered in this plan. This exclusion includes, but is not limited to, commercial weight loss programs (Weight Watchers, Jenny Craig, LA Weight Loss) and fasting programs. This exclusion does not apply to medically necessary treatments for morbid obesity or dietary evaluations and counseling, and behavioral modification programs for the treatment of anorexia nervosa or bulimia nervosa. Surgical treatment for morbid obesity is covered as described in the Evidence of Coverage (EOC).
Sex Transformation. Procedures or treatments to change characteristics of the body to those
PHYSICAL MEDICINE HEALTH PROGRAM RIDER
SUMMARY PLAN DESCRIPTION
Your Summary Plan Description is amended by this rider. All other provisions of the Summary Plan Description which are not inconsistent with this rider remain in effect. This rider becomes effective on February 1, 2010. The Chiropractic Care and Physical Therapy, Physical Medicine and Occupational Therapy benefits under the
section of the Summary Plan Description entitled MEDICAL CARE THAT IS COVERED are deleted and
replaced by:
Physical Therapy, Physical Medicine, Occupational Therapy and Chiropractic Care Services. The
following services provided by a physician under a treatment plan which offers a reasonable expectation
of significant improvement:
1. Physical therapy and physical medicine provided on an outpatient basis for the treatment of illness or injury, including the therapeutic use of heat, cold, exercise, electricity, ultra violet radiation, manipulation of the spine or massage for the purpose of improving circulation, strengthening muscles, or encouraging the return of motion. (This includes many types of care which are customarily provided by chiropractors, physical therapists and osteopaths.) 2. Occupational therapy provided on an outpatient basis when the ability to perform daily life tasks has been lost or reduced by illness or injury including programs which are designed to rehabilitate mentally, physically or emotionally handicapped persons. Occupational therapy programs are designed to maximize or improve a patient's upper extremity function, perceptual motor skills and ability to function in daily living activities. Benefits are not payable for care provided to relieve general soreness or for conditions that may be expected to improve without treatment. Outpatient visits will require medical necessity review after the first 5 visits per calendar year. Visits are counted on an annual basis per member, per provider office. The review process for Physical Therapy, Physical Medicine, Occupational Therapy and Chiropractic Care will be managed by American Specialty Health Networks, Inc. (ASH Networks) through a Health Care Service Agreement with Anthem Blue Cross Life and Health Insurance Company (Anthem). The program is designed to assure that the services you receive are medically necessary and appropriate, and that your benefits are used to your best advantage. All Physical Therapy, Physical Medicine, Occupational Therapy and Chiropractic Care services, regardless of the provider type, will be submitted by your provider to ASH Networks for medical necessity review. If the service is within the first 5 visits per member, per provider, the service will be automatically authorized. After 5 visits, services provided by participating providers and non-participating providers may or may not be authorized as medically necessary by ASH Networks. Medical necessity review after the first 5 visits is not required, however it is highly recommended. If the services requested by a non-par provider do not meet medical necessity criteria, the member will be financially responsible for services not approved as medically necessary. Services for Physical Therapy, Physical Medicine, Occupational Therapy and Chiropractic Care are subject to medical necessity by ASH Networks which allows providers and members to know up front what will be covered. If authorization is not obtained, claims for Physical Therapy, Physical Medicine, Occupational Therapy and Chiropractic Care will be reviewed upon receipt of the claim. No benefits are payable unless your coverage is in force at the time services are received, and the
payment of benefits is also subject to all terms and requirements that may be listed elsewhere in this
plan description.
PHYSICAL MEDICINE 02/10
OPPOSITE SEX 18 PLUS DOMESTIC PARTNERSHIP RIDER
SUMMARY PLAN DESCRIPTION
Your Summary Plan Description is amended by this rider. All other provisions of the Summary Plan Description which are not inconsistent with this rider remain in effect. This rider becomes effective on the effective date of your Summary Plan Description. The domestic partner definition under the section entitled HOW COVERAGE BEGINS AND ENDS – HOW
COVERAGE BEGINS is deleted and replaced by:
2. Domestic partner is the employee’s domestic partner of the same or opposite sex. Domestic
partner does not include any person who is in active service in the armed forces. In order for the employee to include their domestic partner as a dependent, the employee and domestic partner must meet the following requirements: Requirements applicable to opposite sex relationships when both persons are under age 62:
a. Both persons are at least 18 years of age and capable of consenting to the domestic partnership. b. Both persons consider each other to be, and hold themselves out as engaged in a relationship of c. Both persons have a common residence and have been living together for at least the past six d. Both persons agree to be jointly responsible for each other’s basic living expenses during their domestic partnership so that anyone who is owed such expenses can collect from either. e. Neither person has any other Domestic Partner, and neither person has had a Spouse or other Domestic Partner within the previous six months from the date of the execution of the Affidavit of Domestic Partnership. The two persons are not related by blood in a way that would prevent them from being married to each other in California. g. If living in a city or county providing for such registration, both persons have registered as domestic partners with a California city or county of the State of California and have provided SISC III with a copy of the Certificate of Domestic Partnership. Requirements applicable to all same sex relationships and opposite sex relationships when
one or both of the persons engaged in an opposite sex relationship are over the age of 62 and
meet the criteria set forth below under g.ii.
a. Both persons are at least 18 years of age and capable of consenting to the domestic partnership. b. Both persons consider each other to be, and hold themselves out as engaged in a relationship of c. Both persons have a common residence. d. Both persons agree to be jointly responsible for each other’s basic living expenses during their domestic partnership so that anyone who is owed such expenses can collect from either. e. Neither person is married or a member of another domestic partnership. OPPOSITE SEX 18+ DP 10/12
The two persons are not related by blood in a way that would prevent them from being married to each other in California. Both persons are members of the same sex; or ii. One or both of the persons meet the eligibility criteria under Title II of the Social Security Act as defined in 42 U.S.C. Section 402(a) for old-age insurance benefits or Title XVI of the Social Security Act as defined in 42 U.S.C. Section 1381 for aged individuals. Notwithstanding any other provision of this section, persons of opposite sexes may not constitute a domestic partnership unless one or both of the persons are over the age of 62. h. Neither person has previously filed: (1) a Declaration of Domestic Partnership with the California Secretary of State, or a similar form with another governing jurisdiction, that has not been terminated pursuant to the laws of California, or of that other jurisdiction; or, if (1) does not apply, (2) an affidavit with SISC III declaring they are part of a domestic partnership that they have not been terminated by giving SISC III written notice that it has. It has been at least six months since: (1) the date that the Notice of Termination of Domestic Partnership was filed with the California Secretary of State, or similar form was filed with another governing authority; or, if (1) does not apply, (2) either person has given written notice to SISC III that the domestic partnership they declared in an affidavit, given to SISC III, has terminated. This item does not apply if the previous domestic partnership ended because one of the partners died or married. If they reside in the State of California, must file a Declaration of Domestic Partnership with the California Secretary of State pursuant to Division 2.5 of the California Family Code to establish their domestic partnership. The employee must provide SISC III with a certified copy of the Declaration of Domestic Partnership that was filed with the California Secretary of State; ii. If they reside in another state or governing jurisdiction that registers domestic partnerships, they must register their domestic partnership with that state or governing jurisdiction. The employee must provide SISC III with a certified copy of the document that was filed with the governing jurisdiction registering their domestic partnership; or iii. If the employee and their domestic partner do not reside in a city, county or state that allows them to register as domestic partners, they must provide SISC III with a signed, notarized, affidavit certifying they meet all of the requirements set forth in 2.a through 2.i above, inclusive. Note: For the purposes of 2.j.i above, if the employee and their domestic partner registered their
relationship prior to July 1, 2000, with a local governing jurisdiction in California, in lieu of
supplying SISC III with a certified copy of the Declaration of Domestic Partnership (a State of
California form), the employee may provide SISC III with a certified copy of the form filed with the
local governing jurisdiction.
OPPOSITE SEX 18+ DP 10/12
For the purposes of this provision, the following definitions apply: "Have a common residence" means that both domestic partners share the same residence. It is not necessary that the legal right to possess the common residence be in both of their names. Two people have a common residence even if one or both have additional residences. Domestic partners do not cease to have a common residence if one leaves the common residence but intends to return. "Basic living expenses" means shelter, utilities, and all other costs directly related to the maintenance of the common household of the common residence of the domestic partners. It also means any other cost, such as medical care, if some or all of the cost is paid as a benefit because a person is another person's domestic partner. "Joint responsibility" means that each partner agrees to provide for the other partner's basic living expenses if the partner is unable to provide for herself or himself. Persons to whom these expenses are owed may enforce this responsibility if, in extending credit or providing goods or services, they relied on the existence of the domestic partnership and the agreement of both partners to be jointly responsible for those specific expenses. OPPOSITE SEX 18+ DP 10/12
SISC CO-PAYMENT REFERENCE GUIDE
Medco manages your prescription drug benefit at the request of SISC. Your plan gives you
the option of getting your covered medications through the Medco Pharmacy® mail-order
service or at a participating retail pharmacy.
The chart below provides a summary of your prescription drug benefit co-payments.
When you use a participating
When you use the
Type of medication
retail pharmacy, you pay:
Medco Pharmacy, you pay:
$7 co-payment
$14 co-payment
$25 co-payment
$60 co-payment
*A generic drug will always be dispensed if one is available. If you purchase a brand-name drugwhen a generic alternative is available, you will pay the generic co-payment plus the difference incost between the brand and the generic, even if your doctor writes “dispense as written” (DAW) onthe prescription. When you visit a participating retail pharmacy and present your member ID card, you will
pay the applicable cost share and receive up to a 30-day supply of the prescribed drug. For
medication you take on an ongoing basis, using the Medco Pharmacy offers you convenience
and potential cost savings. You can get more information about the Medco Pharmacy
mail-order service by calling 1 800 MEDCO-MAIL (1 800 633-2662).
If you have Internet access, you can visit us online at www.medco.com. After registering,
you can access information about your benefits, as well as health and wellness resources.
You may also contact Member Services toll-free at 1 800 987-5241. Medco looks forward
to meeting all of your prescription benefit needs.
Medications that are not covered by your drug plan
Listed below are medications and medication categories that are not covered under your
SISC drug plan. The list may not reflect all non-covered drugs and may be subject to change.
To confirm whether a prescription drug you need to take is covered or to check the cost of a
medication, visit www.medco.com and click “Price a medication.” (If you’re a first-time visitor
to the site, please take a moment to register. You’ll need your member ID number and the
number from a recent prescription.) You can also get coverage and pricing information by
calling Medco Member Services toll-free at 1 800 987-5241.
Please note that this list may not be all-inclusive.
• Anti-wrinkle agents (Renova®, Retin-A®, and Avita® for patients aged 36 and over)• Experimental drugs• Fertility medications (Follistim®, Gonal-f ®, Clomid®, and Repronex®)• Influenza treatments (for example, Relenza® and Tamiflu®)• Medications labeled “Caution—limited by federal law to investigational use”• Over-the-counter medications • Pigmenting/depigmenting agents (hydroquinone, Eldopaque® and Eldoquin®)• Hair growth and hair removal agents (Propecia® and Vaniqa®)• Smoking-cessation agents (Nicorette®, Zyban®, Chantix™, and all nicotine patches)• Vitamins (except prescription strengths of prenatal vitamins, hematinics, Rocaltrol® • Brand non-sedating antihistamines (for example, Clarinex®, Clarinex-D®, Xyzal®) (See the reverse side for your plan’s co-payment reference guide.)

Source: http://www.hbcsd.k12.ca.us/uploads/2012-2013%20SISC%20Benefit%20Summary%20PPO%2090-A.pdf