Traditional Medical Plan
PRESCRIPTION DRUG PROGRAM SUMMARY AT A GLANCE
Your prescription drug program has a retail pharmacy benefit, home delivery pharmacy benefit and specialty pharmacy benefit. Please refer to the chart below to view the member cost share amounts when using a network retail pharmacy or the home delivery pharmacy. Prescriptions filled at non-network pharmacies are covered by the plan; however, you must complete a claim form and submit to the plan for reimbursement. Plan coverage prior to reaching the out-of-pocket maximum You pay the amounts listed in the chart below until the out-of-pocket amount of $4,000 per individual or $8,000 per family has been reached. The out-of-pocket maximum only applies to pharmacy expenses purchased from network retail pharmacies, the home delivery pharmacy and the specialty pharmacy.
Plan coverage after reaching the out-of-pocket maximum Once the out-of-pocket maximum is met, the plan then pays 100 percent of eligible network prescription drug expenses for the remainder of the calendar year. Purchases from non-network pharmacies do not apply toward the out-of-pocket maximum and you will continue to pay the non-network cost shown below.
Network Certain AllianceRx Non-Network Retail Retail Retail Walgreens Prime Pharmacy Pharmacy Pharmacies Home Delivery (Up to a 30-Day (Up to a 34-Day (Up to a Pharmacy Supply) Supply) 90-Day (Up to a 90-Day Supply) Supply) 10% of the allowed Tier 1 10%, with a $5 $10 copay $10 copay amount, with a $5 minimum and $25 minimum and $25 Generic drugs maximum amount maximum amount. You pay 100% of cost over allowed amount. 20% of the allowed Tier 2 20%, with a $15 $40 copay $40 copay amount, with a $15 Preferred minimum and $75 minimum and $75 brand drugs maximum amount maximum amount. You pay 100% of cost over allowed amount. 30% of the allowed Tier 3 30%, with a $30 $70 copay $70 copay amount, with a $30 Non- minimum and no minimum and no Preferred maximum amount maximum amount. drugs You pay 100% of cost over allowed amount.
7051-BOE B002 06/21 © Prime Therapeutics LLC This information is Proprietary to Prime Therapeutics LLC 1 Member Pays the Difference If you purchase a Tier 2 or Tier 3 brand name medicine at retail or home delivery when a generic equivalent medication is available, you will pay the generic coinsurance/copay, plus the difference in cost between the brand drug and the generic. This cost difference does not apply toward the out-of-pocket maximum.
Preventive Medicines Under the Affordable Care Act, certain preventive medicines are covered at 100 percent. For more information on preventive medicine coverage, please visit myprime.com/boeing or call Member Services at 1-888-802-8776.
Network of Retail Pharmacies You have access to a network of over 67,000 retail pharmacies throughout the United States1. Many chain pharmacies are included in the network, as well as many independent pharmacies.
Approximately 66,000 of these retail pharmacies can provide up to a 90-day supply of long-term maintenance medicines (other than specialty medications, which are described below), offering you choice and convenience. When you use one of these retail pharmacies, you pay the same cost for a 90-day supply as if you used the home delivery (mail order) option.
Long-term maintenance medicine(s) are ones you take on an ongoing basis such as for birth control, high blood pressure, high cholesterol, or diabetes.
To locate a retail pharmacy in your network, including one that offers the 90-day option, please visit myprime.com/boeing and select Find a Pharmacy. Once you’re a member, you can also call the Member Services phone number on your medical ID card.
AllianceRx Walgreens Prime Home Delivery Pharmacy Service Your pharmacy benefit also gives you the option to have your long-term medicines delivered to your home by using the AllianceRx Walgreens Prime home delivery service. AllianceRx Walgreens Prime will deliver up to a 90-day supply to you and standard shipping is free.
AllianceRx Walgreens Prime Specialty Pharmacy Service Specialty medicines are prescribed to treat chronic, complex or rare conditions such as cancer, rheumatoid arthritis and hepatitis C and require close patient monitoring and support. To be covered by the plan, these medicines usually must be purchased through AllianceRx Walgreens Prime. Beginning with the first fill, if you use a pharmacy other than AllianceRx Walgreens Prime to purchase specialty medicines, the plan may not provide coverage and you will be responsible for the full cost. When ordering your specialty medicines through AllianceRx Walgreens Prime, you will receive:
• Up to a 90-day supply of your specialty medication • Most supplies, such as needles and syringes, provided with your medicines • Personalized support from an AllianceRx Walgreens Prime specialty care coordinator • Scheduled delivery of your medicines so you’ll have what you need when you need it • Toll-free access to specialty-trained pharmacists 24/7
For more information or to set up your account for long-term or specialty medicines for home delivery with AllianceRx Walgreens Prime, please visit myprime.com/boeing.
7051-BOE B002 06/21 © Prime Therapeutics LLC This information is Proprietary to Prime Therapeutics LLC 2 Boeing Drug List The Boeing Drug List (sometimes called the formulary) is the list of drugs that are covered by your plan. To determine if your medicine is on the Boeing Drug List, visit myprime.com/boeing and use the Find Medicine feature. Drugs that are not on the Boeing Drug List are not covered. The Boeing Drug List is updated periodically and subject to change.
The pharmacy may contact your doctor about your prescription If you are prescribed a drug that is not on your health plan's formulary, but an alternative covered drug exists, the pharmacy may contact your doctor to ask whether that drug would be appropriate for you. If your doctor agrees to prescribe a formulary drug, you will usually pay less.
Generic drug advantage FDA-approved generic drugs may have unfamiliar names, but the FDA has indicated they are safe and effective. Be assured that FDA-approved generic drugs and their brand-name counterparts:
• Have the same active ingredients • Are manufactured according to the same strict federal regulations
FDA-approved generic drugs may differ in color, size or shape, but the U.S. Food and Drug Administration requires that the active ingredients have the same strength, purity and quality as the brand-name alternatives.
Prescriptions filled with generic drugs often have a lower member cost. Therefore, you may be able to get the same health benefits at a lower cost. You should ask your doctor or pharmacist whether a generic drug would be right for you. You may be able to receive the same high-quality medication but reduce your expenses.
TO GET MORE INFORMATION ABOUT YOUR PLAN Go to myprime.com/boeing Or call Member Services toll free at 1-888-802-8776
1The retail pharmacy network is subject to change at any time.
Certain eligibility provisions apply to each of the programs, policies, and benefits; not all of these provisions are described here. In the event of a conflict between this document and any of the benefit plans, the terms of the plans will control.
Prime Therapeutics manages your prescription plan for The Boeing Company
Prime Therapeutics LLC is an independent company providing pharmacy benefit management services for Boeing health plan members. Prime Therapeutics has an ownership interest in AllianceRx Walgreens Prime, a central specialty pharmacy and mail service company.
MyPrime.com/boeing is an online resource offered by Prime Therapeutics LLC.
7051-BOE B002 06/21 © Prime Therapeutics LLC This information is Proprietary to Prime Therapeutics LLC 3 NOTICE OF NONDISCRIMINATION PRACTICES FOR YOUR PHARMACY BENEFITS Effective October 17, 2016
In compliance with Federal civil rights laws, your employer does not discriminate against, exclude or treat people differently based on race, color, national origin, age, disability, or gender.
Your employer provides resources to access information about your pharmacy benefits in alternative formats and languages: Auxiliary aids and services, such as qualified interpreters and written information available in other formats, are available free of charge to people with disabilities to assist with communication with your employer. Language services, such as qualified interpreters and information written in other languages, are available free of charge to people whose primary language is not English.
If you need these services in relation to your pharmacy benefits, call the phone number on the back of your pharmacy member ID card.
If you believe your employer has failed to provide these services or has discriminated against you in another way based on race, color, national origin, age, disability, or gender in relation to your pharmacy benefits, you may file a grievance with:
Prime Therapeutics c/o Civil Rights Coordination Team 10826 Farnam Drive Omaha, NE 68154
Phone: 1-888-284-2882 TTY: 1-888-284-2882 (agents will connect the member to the TTY service) Fax: 1-877-239-9263 Email: [email protected]
You may file a grievance by mail, fax, or email. If you need help filing a grievance, please contact us using the information listed above.
You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights. electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf by mail: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 Phone:1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
6428-A NA 1557-long 3/17 07003476 English ATTENTION: If you speak a different language, language assistance services are available to you free of charge by calling the telephone number on the back of your pharmacy benefits member identification card.
Spanish ATENCIÓN: Si usted habla espa ol, hay servicios de asistencia idiomática disponibles de forma gratuita comunicándose al n mero telef nico que figura en el reverso de su tarjeta de identificaci n de membresía en beneficios farmacéuticos.
Chinese 注意： 如果您講 國語, 可以透過撥打您的藥品福利會員身份識別卡背面的電話號碼，
獲得免費的語言協助服務。
Vietnamese : Nếu quý vị nói Ngôn ngữ, chúng tôi có dịch vụ hỗ trợ ngôn ngữ miễn cho quý vị khi quý vị gọi số điện thoại ở mặt sau của thẻ danh định thành viên phúc lợi nhà thuốc tây.
Korean
알림: [한국어] 사용자이신 경우 제약 혜택 회원 신분증 뒷면에 나온 전화번호로 전화하면 무료 언어 지원 서비스를 받으실 수 있습니다.
Tagalog PAUNAWA Kung nagsasalita ka ng Tagalog, may maaari kang kuning mga libreng serbisyo ng tulong sa wika sa pamamagitan ng pagtawag sa numero ng telepono sa likod ng iyong pharmacy benefits member identification card.
Russian ВНИМАНИЕ: если вы говорите на русском, языковую поддержку вы можете получить бесплатно, позвонив по номеру, указанному на обратной стороне идентификационной карточки участника системы выплат фармацевтических пособий.
Arabic ﻩﻱﺏﻥﺕ : ﺕﻥﺍ ﻙﺇﺫ ﺍﻝﺕﺕﺡﺩ ﻝﻉﺭﺙ ﺍﻝﻍ ﺕﻡﺍﻑﺥﺩ،ﺓﻱﺏﺓ ﺍﻝﻡ ﺍﻉﺩﺍﺱ ﺓ ﻝﻝ ﻭﻍ ﺍﻥﺝﻡﻙﻝﺓﻑﺭﻡﺓﻱ ﻭﺕ ً ﻥﻉﺍ ﺍﻕﺏﺭﻝﺍﺹﺕﻁﺭ ﺍﻱﻕ ال ﺍﺍﺕﻩﻝﻡ ﺍﻑﻭﺭﻙﻡﺫﻝﻑ ﻩﺝﻭﻝﻱ ﺍﻝﺥﻝ ﻑﻱ ﻝ ﻕﻁﺍﺏ ﺍﻱﺓ ﻩﻭ ﺍﻱﻱﺩﻝﺍﻱﺯﺽﻭﻉﺓﻱ ﻝﻝﺹﻝﻡﺓ ﺕ ﻙﺏﺓﺹﻝﺥﺍﺓ .
6428-A NA 1557-long 3/17 07003476 French Creole ATANSYON: Si ou pale Krey l, sèvis pou ba ou asistans pou lang disponib gratis lè ou rele nimewo telef n ki dèyè kat idantifikasyon ou k m manm benefis pou famasi.
French REMARQUE : Si vous parlez français, vous pourrez contacter gratuitement une équipe d’assistance linguistique en composant le numéro de téléphone au dos de votre carte de membre pour prestations pharmaceutiques.
Polish UWAGA: Jeśli mówisz po polsku, możesz bezpłatnie skorzystać z usług wsparcia językowego. Wystarczy, że zadzwonisz pod numer telefonu podany z tyłu karty identyfikacyjnej uczestnika aptecznego programu korzyści.
Portuguese ATENÇÃO: Se fala português, pode obter serviços de assistência no seu idioma sem custos ao ligar para o n mero de telefone que se encontra na parte de trás do seu cartão de identificação de benefícios para membros da farmácia.
Italian ATTENZIONE: se lei parla italiano, sono disponibili per lei servizi gratuiti di assistenza linguistica chiamando il numero di telefono sul retro della sua scheda identificativa del membro relativa ai benefici farmaceutici.
German HINWEIS: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlose Sprachdienstleistungen zur Verf gung. Rufen Sie die Telefonnummer auf der R ckseite Ihres Mitgliederausweises f r pharmazeutische Verg nstigungen an, um diese zu nutzen.
Japanese 注意： 日本語をお話しになる方は、薬剤給付メンバー IDカードの裏面に記載の電話番号におかけい ただくと、言語サポートサービスを無料でご利用いただけます。
Persian (Farsi) ﻩﻭﺝﺕ :ﺍگﺭ ﺯﺏ ﺕﺏﻥﺏﺍﻩ ﻥکﺹﺡﻑﺍﺭﺱی ﺥﺩﻡی ﺯﺕﻡﺍﻱﺩ، کﻡک ﺭﺍﻁﻩﺏﻥیﺏﺍ ﻡﻭﺕﻝﻑﺱﻡﺍﺕﺏﺍﻥگﺍﻱﻭﺭ ﺏﺍ ﺵﻡﺍﺭﻩ ﺩﺭﻥ ﺕﺭکﺍﺕﺵپﺝﻭﺩ ﻱیﻥﺍﺱﺍﺵ ﻡﺯﺽﻭﻉ ﺩﺍﻱﺕ ﺵﻩﻥﻭﺥﺍﺭﺍﻱﺍی ﺍی ﻡﺍ ﺩﺭ ﺩﻥﺕﺩﺱﺕﺭﺱ ﻩﺱ .
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