Prescription
Benefits
July, 2006 & July, 2007
The
Ohio Med plans have prescription drug coverage that consists of two parts:
- Retail
medication program for short-term prescription needs from your local
pharmacy; administered by Catalyst Rx through June 30, 2009.
- Mail-order
program which must be used for longer or maintenance prescription
needs; administered by Catalyst Rx through June 30, 2009.
- Drugs that are dispensed by your doctor's office are not covered.
Retail
Program
As a member of an Ohio Med plan, you will receive an Catalyst Rx ID card
to use when you need a short-term prescription. You must use your Catalyst Rx ID card at a network pharmacy when you need a prescription for 30
days or less. Effective July 1, 2006 you may fill a new prescription and one refill at a retail pharmacy.
To
locate a nearby pharmacy, refer to the list of chain pharmacies sent
to you when you enrolled or call Catalyst Rx at 1-866-854-8850 or refer to www.catalystrx.com.
If you need to get a prescription but have not received your Catalyst Rx
ID card, and have paid for a prescription out of your pocket, call
Benefits Administration Customer Service at (800) 409-1205. They will
provide information on how to obtain your prescription and what to
do next. When you are outside Ohio and need a prescription filled,
you will be reimbursed.
Retail
Copays
For up to a 30-day supply, you pay:
Prilosec is an exception to the above copay schedule. If your physician writes a prescription for over-the-counter (OTC) Prilosec, the first fill at retail is free and refills are $5. Refills up to the limit of the written prescription may be obtained at retail.
Obtaining
Multiple Refills at Retail
Although mail order is mandatory, there are several categories of medications
that are uniquely appropriate for multiple refills at your local pharmacy.
If you have a prescription for any of these medications, you can get
multiple refills at your local pharmacy:
- Anti-infectives - this
covers antibiotics (Amoxicillin, Biaxin, etc.), anti-virals (Zovirax,
Famvir), anti-fungals (Diflucan), drops used in the eye and ears (Polsporin
Opth, Cipro Otic, etc.). Not every eye or ear drop is covered—the
key definition is to “treat infection.” Glaucoma drops are
not covered.
- Cough medications - narcotic
(Phenergan with coedeine, Tessalon, Tussionex)
- Pain medications - both
narcotic (Vicodin, Percodan, etc.), and non-narcotic (Darvocet)
- Medications
that require a new written prescription each time you need them because
no refills are permitted by federal law (Percodan, Ritalin, Nembutal,
etc.)
- Medications
used to treat both attention deficit disorder (Ritalin, Cylert) and
narcolepsy (Dexedrine)
- Medications
whose sole use is to treat cancer
Mail-Order
Drug Program
When you need a prescription for long-term or maintenance medications
lasting more than 30 days (in addition to the one allowable refill at retail), you must use the mail-order prescription
program administered by Medco. To obtain an order
form and instructional pamphlet, call Catalyst Rx at 1-866-854-8850, or print one from the Catalyst Rx Web site.
Mail-Order
Copays
For up to a 90-day supply, you pay:
- $25 per prescription
for generic medications
- $55 per prescription for preferred brand-name
medications
- $110 per prescription for non-preferred brand-name medications (when generic is not available)
- $110
plus the difference in cost between the brand name drug and generic
drug for any non-preferred brand-name drug that has a generic equivalent.
If
you do not use the mail-order drug program when it is appropriate to do
so, you must pay the full price for your prescription and you will not
be reimbursed. Be sure to ask your physician to prescribe an initial
30-day supply (and one 30-day refill, if necessary), which you can purchase at a retail pharmacy with your Catalyst Rx ID card, and a 90-day supply plus refills, to be filled through mail
order.
Prescription
Plan Exclusions
The Prescription drug program does not cover the following:
- Appetite suppressants and weight loss medications*
- Drugs dispensed by your doctor's office.
- Drugs labeled “Caution - limited by federal law to investigational use” or experimental drugs, even though a charge is made to the individual
- FluMist
- Jellies, creams, foams and other non-prescription contraceptive devices
- Renova, Vaniqa,
Tri-Luma, Botoc cosmetic, Solage, and Avage
- Medication for which the cost is recoverable under a workers’ compensation or occupational disease law or any state or governmental agency, or medication furnished by any other drug or medical service for which no charge is made to the member.
- Medication to be taken by or administered to an individual, in whole or in part, while he or she is a patient in a licensed hospital, rest home, sanitarium, extended care facility, skilled nursing facility, convalescent hospital, nursing home or similar institution which operates on its premises or allows to be operated on its premises, a facility for dispensing pharmaceuticals.
- Mifeprex
- Non-federal legend drugs (except OTC Prilosec)
- Over-the-counter medications, including Claritin, Prilosec OTC, Zantac 75 and 150, and vitamins
- Retin-A for people over the age of 30*
- Rogaine and Propecia
- Smoking deterrents,
including Zyban and Wellbutrin
- Therapeutic
devices or appliances
*NOTE:
Several medications that are listed under the “Exclusions” section
of the Ohio Med Prescription Plan can be covered if you obtain a Prior
Authorization from Catalyst Rx. They are:
Meridia, Adipex and Xenical (excluded as “anorexiants”) - if your doctor writes a prescription for any of these drugs, have the doctor call Catalyst Rx at 1-866-854-8850. The diagnosis must be for morbid obesity and explain that you are more than 100 pounds overweight, or have a BMI of greater than 35. If this diagnosis is not included or you do not meet the criteria, these medications will not be covered.
Retin-A
(if your are older than age 30) - if you are older than 30 and need Retin-A,
have your doctor call Catalyst Rx at 1-866-854-8850 and explain
the specific medical reason for the prescription, and provide the type of Retin-A and the strength.
9/4/07
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