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Prescription Coverage Wood County Employee Health Benefits Select Over-the-Counter (OTC) If approved by the Medical Manager an effective 2014 Formulary Prescription Coverage date will be assigned based upon the date signed The following Over-the-Counter (OTC) by the provider on the Medical Necessity Review Schedule of Benefits as of Jan. 1, 2014 medications are available at no cost to the of Excluded Drugs/ Override form. The Benefits The following is a listing of drugs broken down by Subscriber with a valid prescription. To Coordinator will notify the Subscriber and the conditions they are used to treat. Under each The Plan pays all covered charges incurred in receive the benefit at the retail pharmacy, the Prescription Drug carrier of the effective date. condition, the drugs are listed in three tiers. Tier I excess of the co-pay amount. Subscriber must submit a valid prescription at Purchases after the effective date may be eligible is the least expensive; followed by Tier 2 which is the pharmacy counter for payment through for reimbursement allowable under the Plan. less expensive; and Tier 3 which is the most Benefits apply for prescriptions purchased at the pharmacy benefits. A 90-day supply of Approvals are subject to the plan design and any expensive. Tier 1 drugs always costs the least Participating Pharmacies only. Visit the employee one of the following OTC medications may future plan changes. amount and are as effective and safe as Brand website for a listing of participating pharmacies. also be purchased through the mail order Drugs. Remember: Select Over-the-Counter program by sending in a valid prescription. When a brand product is dispensed solely at the RxEOB drugs with a valid prescription are free to you and request of the Subscriber and a generic equivalent Prilosec OTC Tablets 20mg, Zantac OTC, save the Plan the most money. Use RxEOB to shop for the most appropriate and is available, the Subscriber is responsible for any omeprazole OTC, Prevacid OTC, Zegerid lowest cost drug for you and the Plan. View cost differential between the two products in While there are more than 10,000 drugs available OTC pharmacy benefits and get price quotes at addition to the co-payment. on the market, this listing provides the most Zyrtec, Zyrtec D, Claritin Syrup, Claritin www.rxeob.com. To register for this service, frequently prescribed medications. If a drug is not Tablets, Claritin Reditab, Alavert Syrup, visit, www.co.wood.oh.us.employee. The included on this list, please contact the Pharmacy Retail Pharmacy Co-Pay Amount Alavert Tablets, store brand loratadine, RxEOB link is under the Insurance link. Benefit Manager. Price fluctuations, changes in Tavist ND Tablets, Dimetapp ND Tablets, Maximum 34 day supply Tier levels, and/or method of purchase (retail/mail Claritin-D 12 Tablets, Claritin-D 24 Tablets, order) may result in higher out of pocket Selected $0 Prescription Coverage Contact store brand loratadine-D 24 tablets expenses. Drugs may change throughout the OTC Abreva Cream (for cold sores and fever Information year. Tier 1 $5 blisters) Pharmacy Benefits Manager Tier 2 $15 plus 20% of the Average Alaway, ketotifen, Zaditor (Ophthalmic) Pharmacy Benefits Direct Please note that while a drug may be listed in the formulary, the drug may fall under the Wholesale Price (AWP) Slo-Niacin (for cholesterol) Customer Service No. 1.800.806.7859 $35 maximum out-of-pocket Plan’s excluded and limited services listing. Mail Order Benefit Please contact the Pharmacy Benefit Manager Tier 3 $15 plus 20% of the AWP Retail Pharmacies for specific coverage information. $65 maximum out-of-pocket The mail order program allows Subscribers to For a list of participating pharmacies fill a 90-day prescription. The initial order It is important that you share this information with Mail Order Co-Pay Amount requires the original prescription from your see the Network Website: your physician and follow his/her advice. This Maximum 90 day supply doctor. Due to the processing of the order, www.pdmi.com information is not meant as a substitute for the allow 14 days mail time. care of your physician. Rather, it is available to Selected $0 OTC Mail Order help you and your physician select a less Refills may be obtained by calling a toll free expensive drug that will work for you. Tier 1 $10 number or ordering online. Refer to the MEDVANTX Prescription Coverage Contact Information in Tier 2 $30 plus 20% of the AWP Customer Service: 1.866.744.0621 DRUGS FOR INFECTIONS the back of this booklet. $70 maximum out-of-pocket PO Box 5736, ANTIBIOTICS------------------------------------------------- Sioux Falls, SD 57117-5736 Penicillins . Tier 3 $30 plus 20% of the AWP Medical Review Tier 1 ampicillin, amoxicillin, cloxacillin, dicloxacillin, www.medvantxrx.com $130 maximum out of pocket Coverage for excluded and limited services amoxicllin w/ potassium clavulanate, penicillin may be authorized and approved by the Cephalosporins. See the Plan Document for a complete list of Tier 1 cefaclor, cefadroxil, cefdinir, cefradine, Excluded and Limited Services. Medical Manager and/or Plan Administrator Employee Website cefpodoxime, cefprozil, cefuroxime, based on medical necessity. Subscribers www.co.wood.oh.us/employee cephalexin If approved under the Medical Review Process, seeking coverage for a prescription on the Provides links to plan and network Tier 3 Cedax, Spectracef, Suprax prescriptions are covered at the following level: Excluded and Limited Services listing shall Macrolides . information, access to Subscriber Booklet, Pharmacy: $15 plus 50% of the AWP; complete a Medical Necessity Review form with Tier 1 azithromycin, clarithromycin, erythromycin claim, and reimbursement forms, along with ethyl succinate, erythromycin stearate maximum $150 out-of-pocket physician assistance prior to purchase. Forms are available from a Group wellness program information. Tier 2 clarithromycin ER Tier 3 Dificid, EryPed, PCE, Zmax Mail Order: $30 plus 50% of the AWP: Representative or on-line. Completed forms Tetracyclines. maximum $300 out-of-pocket shall be returned to the Benefits Coordinator in Database of Low Cost/Free Tier 1 doxycycline, minocycline, tetracycline the Commissioners’ Office for processing. Medications Tier 3 Adoxa, Doryx, Oracea, Solodyn Insufficient or incomplete information may result Quinolones . www.hylant.medtipster.com in a delay or denial of claim. Tier 1 ciprofloxacin, levofloxacin, ofloxacin Find free or low cost medications at local Tier 2 Avelox, ciprofloxacin XR pharmacies Tier 3 Factive, Noroxin This document is in effect January 1, 2014. Printed 12/10/2013 - Formulary consultation and administrative support to provided by: Engineering Efficient + Effective Drug Therapy ™ Page 1 of 8 Aminoglycosides. Tier 3 Estrace Vag Cream, Alora, Climara, MISCELLANEOUS ENDOCRINE MISCELLANEOUS CARDIOVASCULAR DRUGS-------- Tier 1 Neomycin Tablets Estraderm, Estrasorb, Estring, Tier 3 Bidil Tier 2 cabergoline, desmopressin, Zemplar Sulfonamides. .. Estrogel, Femring, Menest ANTICOAGULANTS/ANTITHROMBOTICS----------------- Tier 3 Carnitor, Hectoral Tier 1 sulfisoxazole w erythromycin ethylsuccinate ESTROGEN COMBINATIONS------------------------------- Tier 1 anagrelide, cilostazol, clopidogrel, dipyridamole, sulfamethoxazole w trimethoprim (SMX-TMP) Tier 1 estradiol & norethindrone acetate CARDIOVASCULAR DRUGS pentoxifylline, ticlopidine, warfarin Drugs for Tuberculosis. ethinyl estradiol & norethindrone acetate CARDIOTONICS ------------------------------------------------- Tier 2 enoxaparin Tier 1 ethambutol, isoniazid, pyrazinamide, rifampin esterified estrogens & methyltestosterone Tier 1 Digoxin Tier 3 Aggrenox, Brilinta, Effient, Pradaxa, Xarelto Tier 3 Mycobutin, Priftin, Rifamate, Seromycin Tier 2 Premphase, Prempro, Combipatch ANTI-ANGINA ---------------------------------------------------- DRUGS FOR MISCELLANEOUS BLOOD DISORDERS- Sirturo, Trecator Tier 3 Angeliq, Climara Pro, Femhrt, Jinteli, Prefest Tier 1 isosorbide dinitrate, isosorbide mononitrate Tier 1 aminocaproic acid, pentoxyfylline, Drugs for Fungal Infections. PROGESTINS ---------------------------------------------------- Tier 2 Nitrostat subligual tabs Tier 2 Exjade Tier 1 fluconazole, ketoconazole, nystatin, terbinafine Tier 1 medroxyprogesterone, megestrol Tier 3 Dilatrate-SR, Nitrolingual, Ranexa Tier 3 Mephyton, Samsca Tier 2 itraconazole, voriconazole Tier 2 Crinone, Endometrin BETA-ADRENERGIC BLOCKERS---------------------------- RESPIRATORY / ASTHMA Tier 3 Ancobon, Grifulvin-V, Gris-Peg, Noxafil Tier 3 Prometrium Tier 1 atenolol, carvedilol, metoprolol, metoprolol XL, DRUGS FOR ALLERGY ------------------------------------------- Drugs For Viral Infections - Influenza & RSV . propranolol, propranolol LA, DRUGS FOR DIABETES Oral Antihistamines and Combinations. Tier 1 amantadine, rimantidine Tier 2 Bystolic INSULINS ---------------------------------------------------------- OTC Zyrtec, Zyrtec D, Claritin Syrup, Claritin Tablets, Tier 2 Tamiflu Tier 3 Coreg CR, Innopran XL, Levatol Tier 1 Humulin R, N, 70/30 Claritin Reditab, Alavert Syrup, Alavert Tablets, Tier 3 Relenza CALCIUM CHANNEL BLOCKERS --------------------------- Tier 2 Humalog, Humalog 3ml, Humalog KwikPen, store brand loratadine, Tavist ND Tablets, Drugs For Viral Infections - Herpes. Tier 1 amlodipine, diltiazem, diltiazem CD, diltiazem Humalog Mix, Humalog Mix 3ml, Dimetapp ND Tablets, Claritin-D 12 Tablets, Tier 1 acyclovir SR, felodipine, nifedipine XL, verapamil SR Humulin U500, Lantus, Lantus 3ml, Lantus Claritin-D 24 Tablets,
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