There are important features you should be aware of. These include:

• Who can write your prescription. Any covered provider licensed to prescribe drugs may write your prescription.
• Where can you obtain them. You can fill the prescription at a Medco Health network pharmacy, a non-network pharmacy, or by mail. We pay our highest level of benefits for mail order and you should use the mail order program to obtain your maintenance medications.
• We use a formulary. Our formulary is open and voluntary. A formulary is a list of medications we have selected based on their clinical effectiveness and lower cost. By asking your doctor to prescribe formulary medications, you can help reduce your costs while maintaining high-quality care. Use of a formulary drug is voluntary; there is no financial penalty if your physician does not prescribe a formulary drug.
• Brand/Generic Drugs
  • Why use generic drugs? A generic drug is a chemical equivalent of a corresponding name brand drug. The US Food and Drug Administration sets quality standards for generic drugs to ensure that these drugs meet the same standards of quality and strength as brand name drugs. Generic drugs are less expensive than brand drugs, therefore, you may reduce your out of-pocket-expenses by choosing to use a generic drug.
  • 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, and your physician has not received a preauthorization, you have to pay the difference in cost between the name brand drug and the generic, in addition to your coinsurance. However, if your doctor obtains preauthorization because it is medically necessary that a brand name drug be dispensed, you will not be required to pay this cost difference. Your doctor may seek preauthorization by calling 1-800-753-2851.
  • The Plan may have certain coverage limitations to ensure clinical appropriateness. For example, prescription drugs used for cosmetic purposes may not be covered, a medication might be limited to a certain amount (such as the number of pills or total dosage) within a specific time period, or require authorization to confirm clinical use based on FDA labeling. In these cases, you or your physician can begin the coverage review process by calling Medco Health Customer Service at 1-800-841-2734.

• These are the dispensing limitations.
  • The Medco Health Retail Network - you may obtain up to a 30-day supply plus one 30-day refill for each prescription purchased from a Medco Health network pharmacy. After one 30-day refill, you must obtain a new prescription and submit it to the mail order program. If you do not, we will pay the non-network pharmacy benefit level. To receive maximum savings you must present your card at the time of each purchase, and your enrollment information must be current and correct. In most cases, you simply present the card together with the prescription to the pharmacist. Refills cannot be obtained until 75% of the drug has been used.
  • Exceptions for special circumstances - The Plan will authorize up to a 90-day supply at a network pharmacy for covered persons called to active military service. Also, the Plan will authorize an extra 30-day supply, either at network retail or Home Delivery, for civilian Government employees who are relocated for assignment in the event of a national emergency. Authorization may be obtained from Medco Health at 1-800-841-2734 or from the Plan at 1-800-222-APWU (2798).
  • Non-network pharmacy - if you do not use your identification card, if you elect to use a non-network pharmacy, or if a Medco Health network pharmacy is not available, you will need to file a claim and we will pay at the non-network retail pharmacy benefit level.
  • Mail order - through this program, you may receive up to a 90-day supply of maintenance medications for drugs which require a prescription, diabetic supplies and insulin, syringes and needles for covered injectable medications, and oral contraceptives. Some medications may not be available in a 90-day supply from Medco Health Home Delivery Pharmacy Service even though the prescription is for 90 days.
  • Refills for maintenance medications are not considered new prescriptions except when the doctor changes the strength or 180 days has elapsed since the previous purchase. Refill orders submitted too early after the last one was filled are held until the right amount of time has passed. As part of the administration of the prescription drug program, we reserve the right to maximize your quality of care as it relates to the utilization of pharmacies.
  • You may fill your prescription at any pharmacy participating in the Medco Health system. For the names of participating pharmacies, call 1-800-841-2734.

  Certain controlled substances and several other prescribed medications may be subject to other dispensing limitations, such as quantities dispensed, and to the judgment of the pharmacist.

• Personalized Medicine (voluntary program)
  The Personalized Medicine Program combines a Pharmacogenomic test (genetic lab test) with a clinical program to optimize prescription drug therapies for patients taking Warfarin (anticoagulant) and Tamoxifen (for breast cancer). This program focuses on giving physicians information, on an individual level, on patients who have already been diagnosed with a disease or condition.

  The benefits of this testing, done with a simple cheek swab are:

  • Greater patient safety and efficacy through more precise dosing for Warfarin and correct therapy decisions for Tamoxifen
  • Elimination of adverse events since the patient will be taking the right dose of Warfarin from the early onset of therapy

  Pharmacogenomic testing gives physicians personalized information they can use to make more precise prescribing and dosing decisions to help their patients receive the critical care they need. The Personalized Medicine Program is available to you at no additional cost. If your medication history indicates that the testing could be beneficial for you, a pharmacist will contact your physician to discuss the program. If your doctor agrees that the test results would be helpful, you will be contacted by a pharmacist to let know that the testing is available. If you agree to participate, you will receive a cheek swab test that you can administer on your own.

  The results of your test will be sent to your doctor and to a Medco pharmacist who has received special training in personalized medicine. The pharmacist is available to help your doctor interpret the results of your test. Your participation is voluntary, and your doctor is still solely responsible for deciding which drug and dose is right for you.

  Coverage Authorization

  • The information below describes a feature of your prescription drug plan known as coverage authorization. Coverage authorization determines how your prescription drug plan will cover certain medications.

    Some medications are not covered unless you receive approval through a coverage review (prior authorization). Examples of drug categories that require a coverage review include but are not limited to, Growth Hormones, Botox, Interferons, Rheumatoid Arthritis agents, Retin A and drugs for organic impotence. This review uses plan rules based on FDA-approved prescribing and safety information, clinical guidelines and uses that are considered reasonable, safe and effective. There are other medications that may be covered with limits (for example, only for a certain amount or for certain uses) unless you receive approval through a review. During this review, Medco asks your doctor for more information than what is on the prescription before the medication may be covered under your plan. If coverage is approved, you simply pay your normal copayment for the medication. If coverage is not approved, you will be responsible for the full cost of the medication.

    The Plan will participate in other approved managed care programs to ensure patient safety and appropriate therapy in accordance with the Plan rules based on FDA-guidelines referenced above.

    To find out more about your prescription drug plan, please visit Medco online at www.medco.com or call Medco Member Services at 1-800-841-2734.

  • "Specialty Drugs" means those covered drugs that typically cost $500 or more per dose or $6,000 or more per year and have one or more of the following characteristics: (1) complex therapy for complex disease (2)specialized patient training and coordination of care (services, supplies, or devices) required prior to therapy initiation and/or during therapy; (3) unique patient compliance and safety monitoring requirements; (4)unique requirements for handling, shipping and storage; and (5) potential for significant waste due to the high cost of the drug.

    Exceptions to the price threshold may exist based on certain characteristics of the drug or therapy which will still require the drug to be classified as a Specialty Drug. Some examples of the disease categories currently in Medco's specialty pharmacy programs include cancer, cystic fibrosis, Gaucher disease, growth hormone deficiency hemophilia, immune deficiency, Hepatitis C, infertility, multiple sclerosis, rheumatoid arthritis and RSV prophylaxis.

    In addition, a follow-on-biologic or generic product will be considered a Specialty Drug if the innovator drug is a Specialty Drug.

    Many of the specialty drugs covered by the Plan fall under the Coverage Authorization program mentioned above.