These are only examples and not an exhaustive list. Please call Medco Health Solutions, Inc. at
(800) 711-0917, if you have questions about coverage and/or limitations on the dosage quantity
amount covered for a specific prescription drug.
Mail Order Pharmacy Benefits
You are encouraged to use Medco by Mail, your plan’s mail-order pharmacy, if you are taking medication on a regular or long-term basis for 90 days or longer to treat an ongoing health condition such as high blood pressure, high cholesterol, asthma, diabetes, or if you are taking oral contraceptives. Licensed professionals will fill your prescriptions following strict quality and safety controls. If you do not use the Mail Order Pharmacy for maintenance medications after the first two (2) fills, you will pay 100% of the drug’s cost.
How to Get Started Using the Mail Order Benefit
Ask your doctor to write two prescriptions, one for your initial 30-day supply which you can fill at your local participating retail pharmacy and the second for a mail order prescription for a 90-day supply. Also ask your doctor to write a prescription for appropriate refills for up to one year (for example, three additional 90-day supplies). Certain state laws require maximum time periods for mail order refills which may be less than one year.
Complete the member profile (Health, Allergy and Medication Questionnaire) on the pre-addressed mailer attached to the center of your new member handbook. If you need to obtain a member profile form and/or pre-addressed mail order envelopes, contact Medco Health Solutions, Inc. by phone at (800) 711-0917 or online at www.medco.com.
You only need to complete the profile with your first mail order submission. Be sure to include your member ID number, appropriate co-payment/coinsurance and your prescription in the mailer envelope.
Standard mail order shipping is free. Your first mail order medication order will usually be received within eight days after Medco receives your order. Subsequent mail orders (refills) take approximately seven days, often less, from the date you place the order to receipt of the medication at the address you have designated.
Overnight or second-day delivery may be available for your area for a charge. Along with your medication, you will receive a form to remind you when to order your refill. You should order your next refill 21 days before your current supply of medication runs out to allow sufficient time for your request to be filled and shipped without causing you concern about getting your medication on time.
Refilling Your Mail Order Prescriptions
Provided refills are authorized, a prescription may be refilled up to one year after the date it was issued. Certain state laws prohibit one year refills, but allow for more than 90 days. Federal law limits controlled substances to a six-month timeframe;
after that, a new prescription is needed.
You may order refills in one of three ways:
• Refills online — Go to the member website at www.medco.com.
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Refills by phone — Call (800) 473-3455. Have your member ID number, your refill slip with the prescription number, and your credit card ready.
Refills by mail — Use the refill and order forms provided with your medication. Mail them with your copayment/co-insurance to:
Medco Health Solutions P.O. Box 30493 Tampa, FL 33630-3493
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You may pay by check, money order, VISA, MasterCard, Discover/NOVUS, American Express or Diners Club. Call the Medco Health Solutions, Inc. Helpline at (800) 948-8779 or TTY (for the hearing impaired) at (800) 759-1089. If you send the wrong co-payment/co-insurance amount and there is a balance due, an invoice will be included with your prescription order. If you have overpaid, your account will be credited.
Note:
• The mail order pharmacist’s professional judgment and regulations surrounding dispensing quantity restrictions govern certain controlled substances and other prescribed drugs. Federal law prohibits the return of dispensed controlled substances.
The state of Pennsylvania limits “as needed” refills on each prescription to five times or six months, whichever is less.
Prescription orders will not be filled more than 12 months after issuance, more than six months after issuance for controlled drug substances or if prohibited by applicable law or regulation.
Retail Pharmacy Benefits
When you need to have a prescription filled on a short-term basis, typically for up to a 30-day supply, present your Medco Health Solutions, Inc. member identification card to any pharmacy that participates in the Medco network. Their
computerized system will confirm your eligibility for benefits. If the prescription is covered, the pharmacist will fill your prescription and charge you the appropriate co-payment/coinsurance. You do not need to fill out a claim form for reimbursement as your prescription is processed and paid, minus your co-payment/co-insurance, at point-of-service.
Retail Refill Allowance
If you are filling a prescription for a maintenance drug (an on-going prescription), you will be allowed two fills at the retail pharmacy. On the third fill, if you have not transitioned your prescription to mail order, you can fill your prescription at the retail pharmacy; however, you will be required to pay the full cost of the drug rather than a co-payment/co-insurance.
Finding a Participating Pharmacy
A list of pharmacies that participate in your plan is included in your new member ID card materials and by logging on to the website, www.medco.com or by calling the toll-free Medco Member Services at (800)711-0917.
What Happens if You Do Not Have Your ID Card
If you cannot verify eligibility by showing your ID card, you must pay the full cost of the prescription and file a paper claim for reimbursement. Paper claim forms are available on the Collective Brands benefits website at
www.mycollectivebrands.com, or by calling the toll-free Member Services number, (800) 711-0917, to request that a form be mailed to you. This form must accompany your prescription drug paid receipt and be mailed to the address on the form. You will be reimbursed minus your plan required co-payment/co-insurance.
Co-payments/co-insurance
You will pay a copay for prescriptions filled with a generic drug; and, co-insurance for formulary brand and non-formulary brand name drug. Please see the Formulary section below for a more detailed explanation.
Formulary Drugs
The formulary is a list of commonly prescribed brand-name and generic drugs that Medco Health Solutions, Inc. has listed as preferred, based on their clinical effectiveness and opportunities to help contain the cost for you and the Plan. The formulary list is included in your new member ID card packet. You may also view the formulary at the member website
www.medco.com. The website also allows you to enter the name of your medication to learn whether or not it is on the formulary. If not, the website will list alternative drugs that are on the formulary.
Use of a formulary drug is voluntary; however, your prescription cost will be higher for you, if a generic is available.
Sometimes your doctor may prescribe a medication for which either a formulary brand-name or generic alternative drug is available. In such cases, your doctor may specify that a prescription be dispensed as written (DAW). The pharmacist may ask your doctor whether an alternative generic drug might be appropriate for you. If your physician agrees, your prescription will be filled with the alternative drug. A confirmation letter will be sent to you and your doctor explaining the change. Ask your doctor if you have questions about a change in prescription. Your doctor always makes the final decision on your medication, and you can always choose to obtain the original medication. Pharmacies will dispense only the medication authorized by your doctor. Whenever a generic is available and you or your doctor choose to not fill with the generic the prescription co-payment will be the generic co-pay plus the cost difference between the generic and the brand drug.
Generic Drugs
Generic drugs are regulated by the federal government to be chemically and therapeutically the same as the equivalent brand name drugs. Generic drugs are made by competing drug companies after the brand name manufacturer’s patent expires.
Additional Prescription Drug Plan Requirements
There are additional criteria which are considered in determining which drugs are covered under the pharmacy benefit and in what amount or dosage. These are two examples of additional plan requirements:
Prior Authorization
The benefit plan identifies certain drugs as “prior authorization” drugs. Medco Health Solutions must review prescriptions for these medications with your doctor before they can be filled under your plan, since more information than what is on a prescription is needed. The review uses plan rules based on FDA-approved prescribing and safety information, clinical guidelines, and uses that are considered reasonable, safe, and effective. Some products, such as those that are used for cosmetic purposes, are specifically excluded from coverage.
If the medication you are trying to fill has a prior authorization requirement under the Plan, the pharmacist will inform you of this. To request a prior authorization, your physician must provide information to Medco Health Solutions’ prior authorization unit. To do this, they must call in the required information to a special toll-free phone number at
(800) 753-2851. Response to a physician’s prior authorization request can take from one to two business days. Both the patient and physician will be notified in writing when the review process is completed. If your medication is approved for coverage, an automatic authorization will be entered in the system to allow your pharmacist to fill your medication for your regular plan co-payment/co-insurance. If your medication is not approved for coverage, you will have to pay the full cost of the drug.
Your doctor can ask for a reconsideration of a prior authorization denial by submitting further information to the prior authorization unit. If reconsideration for the coverage is denied, you must file an appeal with the Plan for further consideration of coverage.
Please see the ERISA section of the summary plan description for information on how to file an appeal with the Plan.
This summary plan description should also be referred to for general information about your Plan.
Quantity Level Limits
In most cases, when you fill a prescription you will receive the prescribed amount, up to a 30-day supply from the retail pharmacy or a 90-day supply from the mail order pharmacy. Certain drugs are limited to a set quantity, regardless of what your physician prescribes. Please call Medco Health Solutions, Inc. at (800) 711-0917 or refer to the website at
Drugs Not Covered
The following drugs are specifically not covered under any of the prescription drug plan options:
• Drugs or medicines that can be obtained without prescriptions (also called over-the-counter, or OTC), or that have an OTC equivalent
• Drugs used for cosmetic reasons
• Drugs used for weight loss
• Vitamins and minerals
• Experimental drugs or drugs under federal investigation
• Legend homeopathic drugs
• Medication which is to be consumed by or administered in a doctor’s office, hospital, extended care facility, nursing home or similar institution; or the charge for administering medication
• Medication which is covered under your self-insured medical plan option