* This section is provided for Members with prescription coverage only. If you are uncertain about your coverage please contact our Pharmacy Services Department at 1.800.624.6961, ext. 7914. SecureCare Part D members please refer to the Medicare section of The Health Plan's website for general benefit information.

• Pharmacy Benefits Program
• Definitions
• Exclusions & Limitations
• Procedures to Obtain Prescription Benefits
• Non-Formulary Requests
• Out-of-Area Emergencies
• 72-hour Cancellation Right
• Coordination of Benefits when Family Covered by More than One Group Health Plan

Pharmacy Benefits Program

The following are pharmacy benefit program descriptions and procedures for use by members with group pharmacy benefit riders.

Prescription drugs are an integral component of a comprehensive health maintenance plan. The Health Plan, through the efforts and recommendations of medical specialists, family practitioners and pharmacists, has developed the following pharmacy benefit designs. This group of actively participating providers, known as the Pharmacy and Therapeutics Committee, has evaluated the therapeutic classes of drugs and their cost effectiveness. The result of that evaluation, which was based on sound clinical evidence, is the creation of a list of drugs (formulary) to allow for the availability of appropriate medications for our members' needs. Also, the formulary allows the prescription costs, and your premium, to be maintained at affordable levels.

The Pharmacy and Therapeutics Committee has further developed and recommended to The Health Plan policies and procedures to direct the use of prescriptions within The Health Plan. These policies and procedures are designed to enhance the appropriate use of prescriptions in both a clinical and cost effective manner.

It is the policy of The Health Plan of the Upper Ohio Valley to utilize the services of a pharmacy benefits manager (PBM) to administer its prescription benefits to members. Medco Health Solutions is the current PBM for The Health Plan. You can contact Medco at 1.800.988.2262 or via the web at www.medcohealth.com.

Definitions

Prescription - Drugs which can only be dispensed upon order (prescription) by a qualified provider of care. Additionally, only drugs which are labeled "Caution federal law prohibits dispensing without prescription" will be considered eligible.

Generic Drug- A drug available as a chemically and therapeutically equivalent copy of a brand name drug. It is usually available from several manufacturers. Generics must meet federal standards for potency and bio-availability.

Brand Drug - A prescription item only available from a single source supplier.

Multi Source Brand Drugs - Brand name drugs which are manufactured by more than one producer. These agents are usually available as Generic equivalents.

Over the Counter Drugs (OTC) - Drugs which are not restricted to prescription only status. These agents are available for purchase without physician approval and are not covered by The Health Plan.

Home Delivery Service - Certain group benefit designs allow members to receive medications at home via the mail.

Exclusions & Limitations

The following will not be covered or paid for by The Health Plan:

• The charge for any prescription refill other than the number set by the prescriber. Additionally, no refills dispensed more than one year from the date of the original prescription.
• The charge for any prescription, oral or topical, that is prescribed for cosmetic purposes.
• The charge for any medications not FDA-approved for use in the general population. Additionally, use of an FDA-approved drug in the treatment of a non-FDA-approved indication will not be covered.
• The charge for a drug not prescribed by a Health Plan qualified provider except in an emergency situation.
• The charge for any medication covered by any Workers' Compensation or occupational disease laws, any other group policy, or government program which is not The Health Plan's program.
• Vitamins, except for prenatal, are not covered. Prenatal vitamins are covered when related to a pregnancy, only.
• Dental-related prescriptions such as, but not limited to, oral fluorides, dental mouth washes, devices used in dental therapy.
• Prescriptions related to smoking cessation such as, but not limited, to nicotine patches, nicotine gum and Zyban.
• Prescriptions for drugs or devices used to promote weight loss.
• Prescriptions used to treat sexual dysfunction, either oral or topical, or devices used for impotence.
• Any injectable drug except insulin, glycogen and epinephrine emergency kits (Epi Pen). For additional coverage of diabetes supplies please refer to the member handbook.
• Appliances and therapeutic devices which may require a prescription are not covered. These include, but are not limited to, garments, splints, bandages or braces regardless of intended use.
• Certain pharmacy riders have an annual limit for prescription drugs per contract year. Please contact Medco Health to see if your rider has an annual limit.
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Procedures to Obtain Prescription Benefits

Obtaining a prescription
As a Health Plan member, you may obtain your prescription at any participating Health Plan network pharmacy. For the location of a participating pharmacy call Medco Health Solutions at 1.800.988.2262 or visit www.medcohealth.com. You can also print this Prescription Order Fax form out and take to your doctor's office.

Please present your Health Plan Identification Card to the pharmacist with your prescription. You will be required to pay a co-payment ("co-pay") at the time of service based on the prescription plan you are enrolled in. The co-pay levels are printed on your Health Plan ID card under the section Pharmacy Benefit. Your ID card also contains important information to allow the pharmacy to correctly submit your claim to Medco Health.

Co-payment structure for restricted pharmaceuticals:

Specialty drugs
Certain injectable drugs known as specialty drugs may be available through our pharmacy network. These drugs maybe covered under your medical or pharmacy benefit and may have certain co-payment responsibilities and restrictions. Have your provider contact The Health Plan prior to prescribing these agents to obtain information on coverage and limitations and to obtain authorization for dispensing via the pharmacy network. Specialty drugs include agents to treat multiple sclerosis, growth deficiencies, and to stimulate certain blood component growth. Access a list of specialty medications  in the Provider Pharmacy Files & Forms.

Drugs requiring prior authorization
Certain medications are eligible for coverage only after a patient-specific approval has been authorized. Patient specific criteria may include age, gender, and clinical conditions determined by the physician for authorization to be granted for a specific drug. Your physician must contact Pharmacy Services for information on specific drugs and the procedures for authorization. The Physician (provider) information phone number is 1.800.624.6961, ext. 7914.

Quantity per dispensing event (QPC rules)
Generally, The Health Plan allows dispensing of approved medications up to a 31-day supply per co-pay at the retail pharmacy network. Quantity per dispensing event rules (QPC) set thresholds that reduce exposure to unnecessary cost, without creating obstacles to access for most members. Drugs that are subject to QPC rules usually have specific limitations for use approved by the FDA. Examples include drugs to treat migraine headaches. These drugs known as “triptans” are to be used in specific doses up to a defined number of headaches per month. The QPC rules allow this specific number of triptan medications to be dispensed per 31-day benefit period. To inquire about QPC limits, have your provider contact Pharmacy Services Dept. at 1.800.624.6961, ext. 7914.

Generic difference policy (co-payment policy for multi-source drugs)
If a prescription order specifies that a brand name drug must be dispensed when the generic equivalent is available, or the prescription order allows for generic substitution and the member elects to have the prescription filled with a brand name drug instead, the member must pay the brand co-payment plus the difference between The Health Plan cost of a brand name and its generic equivalent (i.e. The Health Plan only pays for the generic cost).

Home Delivery Service
Home delivery service of medications may be available under your group benefit design. Home delivery can save you time and money when you have your maintenance medications dispensed by Medco Health Home Delivery Pharmacies. To see if you have this benefit contact Medco Health at 1.800.988.2262. Dispensing up to 90 days of maintenance medications is allowed in home delivery service, usually at a reduced co-payment for the member.

Non-Formulary Requests (Exception Policy)

Prescriptions for drugs presented to the pharmacy that are not covered due to non-formulary status must be converted to a formulary drug, or the non-formulary drug must be pre-authorized by The Health Plan for a medically appropriate reason. The pharmacist should attempt to contact the prescribing physician and suggest the formulary drug for treatment. If conversion to the formulary drug is authorized, the pharmacist will fill the prescription in the usual fashion and provide the member with appropriate information on proper use of the medication. Should the prescribing physician decide that the original (non-formulary) drug is medically necessary, the physician must contact The Health Plan at 1.800.624.6961, ext. 7914 to initiate a clinical coverage review.

Authorizations will be reviewed according to the following criteria:

• The request for the non-formulary drug is for a condition or medical need not met by existing drugs on The Health Plan formulary, OR
• In the physician's medical judgment, the formulary alternatives have been ineffective in the treatment of the member's disease or condition (documentation in the member's clinical record required), OR
• The formulary alternative causes, or is reasonably expected by the prescriber to cause, a harmful or adverse reaction in the member (documentation in the member's clinical record required).

In cases of an emergency, when the prescribing physician and/or Medco Health cannot be contacted, a 72-hour supply of the non-formulary medication can be filled if necessary. The member will be responsible for the cost; however, the member may submit the receipt to The Health Plan for reimbursement provided the prescription meets the coverage guidelines as further specified in this document.

Out-of-Area Emergencies

In situations of emergency need for a prescription outside The Health Plan service area, please contact Medco Health for the location of a participating pharmacy in that area. Present your Health Plan Identification Card with the emergency prescription and pay your co-payment. If no pharmacy in the area participates with Medco Health, purchase the emergency prescription and send your receipt to The Health Plan. You will be reimbursed in full, less your applicable co-payment, for the prescription provided the prescription meets the guidelines specified in this document.  

72-hour Cancellation Right

Any person obligated for any part of a pre-payment may cancel such agreement within 72 hours after he/she has signed an agreement or offered to enroll. Cancellation occurs when written notice of cancellation is given to The Health Plan. Notice of cancellation shall be considered given when the prospective subscriber mails a certified letter to The Health Plan.

Insurance Fraud Warning: Pursuant to Ohio Revised Code Section 3999.21, "Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud."

Coordination of Benefits when Family Covered by More than One Group Health Plan

If you or your family members are covered by more than one group health care plan, you may not be able to collect prescription benefits from both plans. Each group plan may require you to follow its rules or use a specific formulary, and it may be impossible to comply with both plans at the same time. Before you enroll in this plan, read all of the rules very carefully and compare them with the rules of any other group plan that covers you or your family.  

Restriction on Choice of Providers:
The Health Plan will not pay for services or treatment including prescriptions ordered or rendered by health care providers who are not plan providers unless approved by the plan or in emergency cases. Pharmacies participating with The Health Plan can be found by contacting Medco Health at 1.800.988.2262 or at www.medcohealth.com.