| |
| MEDICAL |
 |
| Prescription
Drugs |
Beginning in 2011 your Valassis medical plan options include outpatient
prescription drug coverage through a program administered by CVS/Caremark.
This plan helps you save money on medically necessary prescribed medications
at participating pharmacies or through the mail order program.
Coverage for drugs requiring a prescription from your doctor and used
for the treatment of disease or injury, subject to plan exclusions and
limitations, is provided through CVS/Caremark's nationwide network of
more than 55,000 participating pharmacies. You will find a list of the
participating pharmacies located near you in CVS/Caremark's Directory
of Participating Pharmacies available online at www.caremark.com.
After paying a co-pay or co-insurance, you may receive up to a 30-day
supply of prescription medication from a participating pharmacy and
up to a 90-day supply through the mail order program. Your CO-pay will
be less for generic drugs, higher for brand-name drugs. Co-pays and
coinsurance for prescription drugs do not apply to your medical plan
deductible or coinsurance limit.
If you have signed up for a Health Care Flexible Spending Account (FSA),
however, you may pay these expenses with before-tax dollars and file
for reimbursement from your FSA. (See Flexible Spending Accounts.)
Under the Prescription Drug Program, you will pay $10 for a generic
drug, 20% coinsurance ($30 minimum and $50 maximum) for a brand-name
(formulary)
drug (unless a generic equivalent is available), and 30% coinsurance
($50 minimum and $75 maximum) for a brand-name (non-formulary) drug
when you buy your prescription drugs at a participating pharmacy. If
you are covered by the Health Choice Savings Plan, you will be covered
at 100% once you meet your deductible. Prior to the deductible being
met, you are responsible for 100% of eligible expenses.
To get the most savings, be sure to ask your physician to prescribe
a generic drug whenever possible.
Identification Card
If you are enrolled in the Blue Cross Traditional PPO or Health
Choice Savings Plans you will receive an ID card from CVS/Caremark that
indicates your coverage in the program.
FSA Debit Card
You can pay your out-of-pocket pharmacy expenses quickly, easily and
automatically from your healthcare flexible spending account (FSA) with
your FSA debit card. When you visit a participating pharmacy, you can
pick up your prescription and pay nothing out-of-pocket at the point
of purchase. Just show your FSA debit card. Then, your co-pay is drawn
directly from your FSA account balance, and processed instantly through
the real-time interface available 24 hours a day, seven days a week.
If you elect Domestic Partner coverage, you will be ineligible to participate
in the FSA debit card feature for FSA claims. Domestic Partners are
not eligible for reimbursement under Flexible Spending Accounts unless
they are IRS-qualified dependents. Any claims for associates and their
dependent children would need to be processed by submitting an FSA claim
form which are located in the FORMS menu above.
HSA Debit Card
If you enroll in the Health Care Savings Plan, you will receive a debit
card for your associate contributions. If you also enroll in a Limited
Purpose Flexible Health Savings Account, you can use the same debit
card for both. Your Limited Purpose Flexible Health Savings Account
will be accessed first, since expenses must be incurred prior to the
end of the plan year.
Generic Drugs
For prescription medication, the brand name is the product name under
which a drug is advertised and sold. Generic equivalent medications
contain the same active ingredients and are subject to the same rigid
Federal Drug Administration (FDA) standards for quality, strength and
purity as their brand-name counterparts. Generally, generic drugs cost
less than a brand-name drug. Whenever appropriate, you should ask your
doctor to prescribe generic drugs.
Mail Order Program
Prescription drug coverage includes a mail order program provided by
CVS/Caremark, which offers a discount on the cost of maintenance medication
and a larger supply (90 days) per prescription. Maintenance drugs are
those you must take every day for the treatment of chronic illness,
such as diabetes, asthma or high blood pressure.
To order a prescription by mail log on to www.caremark.com
or call the toll free customer care number printed on your prescription
ID card.
Prescription Drug Benefits
Following is a summary of your prescription drug benefits for
the Traditional PPO and HealthChoice Savings Plans. Pharmacy benefits
for the Health Choice Savings Plan are 100% after the deductible is
met.
-
Retail pharmacy prescriptions (up to 30-day supply)
Generic: $10 co-pay
Brand-name formulary:
20% coinsurance, with $30 minimum and $50 maximum
Brand-name non-formulary: 30% coinsurance with $50 minimum and $75
maximum
-
Mail order prescriptions (up to 90-day supply)
Generic: $20 co-pay
Brand-name formulary:
20% coinsurance with $50 minimum and $90 maximum
Brand-name non-formulary: 30% coinsurance with $100 minimum and
$150 maximum
Note: Except in emergencies, all prescriptions must
be filled by a participating pharmacy.
Prescription Drug Expenses Not Covered
Prescription medication expenses will not be paid for:
- Drugs that cost less than your copayment
- Contraceptive devices (may be covered under a health care program)
- Administration of drugs or any drug consumed at the time and place
of the prescription order
- Refills not authorized by a physician
- Therapeutic devices or appliances, even if prescribed by a physician
(e.g., supporting garments regardless of their intended use)
- Refills dispensed after one year from the date of the original order
- Prescription drugs prescribed for cosmetic purposes
- Any vaccine given solely to resist infectious diseases
- Any drug determined by Blue Cross Blue Shield to be experimental
or investigational
- Any drug that does not require a prescription
- Drugs or services obtained before the effective date or after the
contract ends
- Nonpreferred co-branded drugs, unless they are preauthorized
- Prescription issued by anyone who is not legally authorized to prescribe
drugs for human use
- Diagnostic agents
- Any drug or device prescribed for indications (uses) other than
those specifically approved by the Federal Food and Drug Administration
- Drugs that are not labeled, "Caution: Federal law prohibits
dispensing without a prescription," except for state-controlled
drugs
- Covered drugs or services dispensed to a member when such services
are benefits under other BCBSM certificates
- Drugs or services covered by government sponsored health care programs,
such as Medicare or TRICARE
- More than 8 doses of any drug approved to treat impotence through
a retail pharmacy
- Any drug approved to treat impotence through home delivery
- Any drug approved to treat infertility
- Any drug approved for weight loss
Specialty Drugs
Specialty Drugs are prescription medications that require special handling,
administration, or monitoring. These drugs are used to treat complex,
chronic and often costly conditions, including: asthma, cancer, chronic
kidney failure, Hepatitis C, HIV/AIDS, multiple sclerosis, organ transplants,
osteoporosis, psoriasis, and rheumatoid arthritis. For additional information
please reference Caremark website
or call the toll free customer care number printed on your prescription
ID card.
Authorization and Clinical Criteria
CVS/Caremark monitors the use of certain medications to ensure members
receive the most appropriate and cost-effective drug therapy. Prior
authorization for these drugs means that certain clinical criteria must
be met before coverage is provided. In the case of drugs requiring step
therapy, for example, previous treatment with one or more formulary
drugs may be required. Your physician can contact CVS/Caremarks's pharmacy
help desk to request prior authorization for these drugs.
The criteria for authorization are based on current medical information
and the recommendations of CVS/Caremark and a group of physicians, pharmacists
and other experts. You may be required to pay the full cost of the drug
if your physician does not obtain prior authorization.
When a brand name drug is requested by you or your physician and a
generic is available, you will be charged the difference between the
brand and generic cost of the drug plus the generic co-pay. This applies
even if your doctor writes dispense as written on your prescription.
Please call the toll free customer care number printed on your prescription
ID card if you have questions about your drug coverage, a drug claim
or filing a benefits exception.
In an Emergency
If, in an emergency situation, you need to use a non-participating pharmacy,
you must submit a paid receipt to CVS/Caremark, along with a claim form.
You will be reimbursed based on CVS/Caremark discounted prices, less
your co-payment or co-insurance.
Claim Forms
You do not have to fill out claim forms when you have your prescription
filled at a participating pharmacy. Simply present your ID card, pay
your co-pay or co-insurance and the pharmacy will do the rest.
Except in emergencies, there are no outpatient prescription drug benefits
payable outside of the network.
If you need more information about your prescription drug program,
visit www.caremark.com or call
the toll free customer care number printed on your prescription ID card.
Important Notice Regarding Your Prescription
Drug Coverage and Medicare
Please link to information regarding Medicare
Part D coverage if you or a covered dependent have Medicare or are
soon to be eligible for Medicare.
 
|