SAG-AFTRA Health SPD

Prescription Drug Benefits

Plan I and Plan II

Prescription Drug Benefits At-a-Glance

Deductible

Plan I – $75 per person; $150 per family
Plan II – $175 per person; $350 per family

Plan I – $75 per person; $150 per family
Plan II – $175 per person; $350 per family

Supply

Up to a 30-day supply

Up to a 90-day supply

Copay

You pay the greater of the two Copays shown:
Generic – $10 or 10% of the total prescription cost
Preferred brand – $25 or 25% of the total prescription cost
Non-preferred brand – $40 or 40% of the total prescription cost
In addition, if you receive a brand name drug when a generic exists, you will pay the difference in cost between the generic and brand name medication.

You pay the greater of the two Copays shown:
Generic – $20 or 10% of the total prescription cost; maximum $50 per prescription
Preferred brand – $50 or 25% of the total prescription cost; maximum $125 per prescription
Non-preferred brand - $100 or 40% of the total prescription cost; maximum $300 per prescription
In addition to the maximum Copays listed above, if you receive a brand name drug when a generic exists, you will pay the difference in cost between the generic and brand name medication.

Preventive Services Prescriptions

Generic prescription medications that appear on the list of Affordable Care Act preventive services are not subject to the Deductible or Copay.

Generic prescription medications that appear on the list of Affordable Care Act preventive services are not subject to the Deductible or Copay.

Long-term Medications (taken for 90 days or more)

Must be obtained through home delivery after the second 30-day fill.

Must be obtained through home delivery after the second 30-day fill.

Specialty Medications

Must be obtained through Express Scripts’ specialty pharmacy, Accredo. Covered as other medications outlined above.

Must be obtained through Express Scripts’ specialty pharmacy, Accredo. Covered as other medications outlined above.

The Plan’s prescription drug benefits are administered by Express Scripts. All Participants eligible for these benefits will receive an Express Scripts ID card, which should be presented at retail pharmacies when filling prescriptions. For Participants who are not eligible for the Express Scripts benefits (see below), prescription drug coverage is provided under the medical benefits at the out-of-network level.

Eligibility

You and your covered Dependents are eligible for prescription drug benefits provided through Express Scripts if the Plan provides your primary coverage, or if your primary plan does not include prescription drug coverage. If Medicare is your primary plan and this Plan provides secondary coverage, you and your covered Dependents are eligible for the Express Scripts benefits, provided you and your spouse do not enroll in a Medicare Part D Prescription Drug Program. If you enroll in Medicare Part D, you will not be eligible for any prescription drug coverage under the Plan.

If this Plan is not your primary plan, or if you owe the Plan money due to audit findings by the Contribution Compliance or Participant Eligibility Departments, your prescription drug benefits will be covered under medical benefits at the out-of-network level.

Annual Pharmacy Deductible

The calendar year Deductible for Express Scripts prescription drug coverage is outlined in the table above. The Deductible applies to both retail pharmacy purchases and home delivery purchases, including specialty medications received through Accredo. The family Deductible is satisfied when at least two or more family members have combined Covered Expenses that exceed the amount of the family Deductible in a calendar year. However, the Plan will not apply more than the individual Deductible to any one family member.

If your eligibility changes from Plan I to Plan II during a calendar year, any charges that were applied toward your Plan I Deductible will apply toward your Plan II Deductible. If your eligibility changes from Plan II to Plan I, the reverse is also true.

The pharmacies where you fill prescriptions will collect charges that apply to your Deductible. However, any price differences between brand name drugs and their generic equivalents (where applicable) do not apply toward your Deductible.

Copays

Your pharmacy Copays are outlined in the table above. Copays vary depending on whether the prescription is a generic, preferred brand or nonpreferred brand drug. If your prescription is for a preferred or non-preferred brand name drug that has a generic alternative, you will be responsible for the generic Copay plus the difference in price between the generic and brand name prescription. You will be responsible for the brand/generic difference even if your doctor indicates “DAW” (dispense as written) or “no substitution” on the prescription. The price differential does not apply toward your Deductible.

Preferred Prescriptions Formulary

The Plan uses Express Scripts’ National Preferred Formulary, which is a list of covered brand name and generic medications. These medications are selected because they can safely and effectively treat most medical conditions while helping to contain costs. A list of the current National Preferred Formulary exclusions is available online at www.express-scripts.com. Medications that are not on the Formulary are not covered.

Retail Pharmacy Benefits

You should use a participating retail pharmacy for short-term prescriptions, such as antibiotics to treat infections. Show your Express Scripts ID card to the pharmacist and pay your retail Copay each time you fill a new prescription.

To find a participating retail pharmacy near you:

  • Ask at your retail pharmacy whether it participates in the Express Scripts network;
  • Visit www.express-scripts.com, log in to the secure website and click “Locate a pharmacy.” If you have not registered on Express Scripts’ website, you will need to do so; or
  • Call Express Scripts at (800) 903-4728.

If you use an out-of-network pharmacy, you must pay the entire cost of the prescription, and then submit a Claim form to Express Scripts. You will be reimbursed the amount that would have been charged by a participating retail pharmacy, minus the required Copay. The discounted cost will count toward your prescription drug Deductible.

If you are eligible for the Plan’s regular prescription drug coverage through Express Scripts, your prescriptions will not be considered under the Plan’s medical benefits except for certain over-the-counter prescriptions under the ACA’s list of approved preventive services. For details, please see here.

Home Delivery Pharmacy Benefits

You must use the home delivery pharmacy for medications that you take on a long-term basis (90 days or more, such as those used to treat high blood pressure or high cholesterol). Each prescription for a long-term medication may be filled no more than twice at a retail pharmacy, for a maximum of a 30-day supply with each fill. All subsequent prescriptions for each long-term medication must be filled through the home delivery pharmacy. If you continue to purchase a long-term medication at a retail pharmacy after the first two 30-day fills, you will pay the entire cost of the medication.

Ordering Prescriptions

The first time you are prescribed a new maintenance medication, ask your Physician for two prescriptions: the first for up to a 30-day supply to be filled at a retail pharmacy, and the second for up to a 90-day supply to be filled through the home delivery pharmacy.

You and/or your Physician may submit prescriptions as follows.

  • By fax from your Physician – Give your ID number to your doctor and have your doctor call (888) EASYRX1 ((888) 327-9791) to obtain fax instructions.
  • Online – Visit www.express-scripts.com and follow the instructions to register for Express Scripts Pharmacy’s home delivery services. Once you have registered, click “Manage prescriptions” and follow the instructions. Express Scripts will contact your Physician to transfer your current prescriptions to the home delivery pharmacy.
  • By mail – Request an order form from the Plan by calling (800) 777-4013 or from Express Scripts by calling (800) 903-4728. Mail your prescription and the required Copay along with the completed order form in the envelope.
    • Express Scripts Home Delivery Service
      P.O. Box 747000
      Cincinnati, OH 45274-7000

Please Note:
The pharmacist’s judgment and dispensing restrictions, such as quantities allowable, govern certain controlled substances and other prescribed drugs. Federal law prohibits the return of dispensed controlled substances.

Delivery of Your Medication

Prescription orders are processed promptly and are usually delivered to you within eight days. If you are currently taking a medication, be sure to have at least a 14-day supply on hand when ordering.

Paying for Your Medication

You may pay by check, money order, Visa, MasterCard, Discover/NOVUS, American Express or Diners Club.

Accredo Specialty Pharmacy Benefits

Specialty medications are drugs that are used to treat complex conditions, such as cancer, growth hormone deficiency, hemophilia, hepatitis C, immune deficiency, multiple sclerosis and rheumatoid arthritis.

These medications must be obtained through Accredo, which is a dedicated specialty pharmacy within the Express Scripts family of pharmacies, rather than at your local retail pharmacy or through your Physician’s office. If you choose to use a pharmacy other than Accredo, you will be responsible for the entire cost of the prescription.

Accredo includes access to nurses who are trained in specialty medications, pharmacist availability 24/7 and coordination of home care and other health care services. They can also arrange for prescriptions to be delivered to a Physician’s office for administration. For more information please call Accredo at (800) 903-4728.

Other Pharmacy Benefit Features

No-Cost Immunizations

The following vaccines are covered at no cost to you if received from an Express Scripts participating pharmacy:

  • Diptheria, Tetanus, Pertussis;
  • Hepatitis A and B;
  • Herpes Zoster (shingles);
  • Human Papillomavirus;
  • Inactive Poliovirus;
  • Influenza (flu);
  • Measles, Mumps, Rubella;
    Meningococcal;
  • Pneumococcal (pneumonia);
  • Rabies;
  • Travel immunizations;
  • Varicella (chickenpox); and
  • Any immunizations required in the event of bioterrorism.

To use this benefit, call your pharmacy first to make sure the vaccine you need is in stock and that the pharmacy provides vaccine administration. Once you have verified that the pharmacy has the vaccine and can administer it, simply visit your pharmacy, present your Express Scripts ID card and the pharmacy will take care of the rest.

Express Scripts’ Personalized Medicine Program

Personalized medicine takes advantage of advances in science to help your Physician make more precise and effective prescription and dosage choices through genetic tests that reveal how your body will metabolize certain drugs.

These tests, called pharmacogenomics tests, offer several advantages, including better outcomes, fewer side effects and less waste. 

If you are using a medication covered by Express Scripts’ Personalized Medicine Program such as warfarin for a heart condition, a pharmacist will contact your doctor to see if it is appropriate for you to participate in the program. If your Physician agrees, you will be contacted by a pharmacist to let you know that the testing is available. If you agree to participate, you will receive a cheek swab test that you can administer on your own. The results will be sent to your Physician and to a specially trained Express Scripts pharmacist who will work with your Physician to interpret the results. Of course, your Physician decides which drug and dose is right for you. 

The Personalized Medicine Program is available to you at no additional cost and requires no action on your part. It is completely voluntary, and any decisions to change treatments or dosages are up to you and your Physician. All information gathered during testing is treated confidentially, and no tests are conducted other than the tests which you specifically authorize. All aspects of the program comply with privacy regulations under the Health Insurance Portability and Accountability Act (HIPAA) and the Genetic Information Non-Discrimination Act of 2008 (GINA), as well as applicable state laws.

Prior Authorization

Most of your prescriptions can be filled without prior authorization at a retail pharmacy. However, some drugs are only covered for certain uses or in certain quantities. Lamisil and Wellbutrin SR are examples of medications that require prior authorization by Express Scripts before they can be covered. If you present a prescription requiring prior authorization, your Physician may need to provide additional information before the prescription is covered.

When you take a prescription that needs prior authorization to the retail pharmacy, the system will automatically review your file (age, sex and history of prior drug therapies) to determine if the medication can be dispensed. The pharmacy will advise you if additional information is required. Either you or the pharmacy can ask your Physician to call Express Scripts at (800) 753-2851 to initiate the prior authorization process. This call will start a review
that typically takes two to five business days, unless additional information is required, in which case, the review may take longer. Both you and your Physician will be notified in writing of the decision.

If the prescription is approved, the letter will tell you the length of your coverage approval. If the prescription is denied, the letter will include the reason for coverage denial and instructions on how to submit an appeal, if you choose to do so. 

If you want the prescription immediately without waiting for the prior authorization, you will have to pay the full retail price at the pharmacy. If the prescription is approved, your Claim should be sent to Express Scripts for reimbursement at 100% minus the prescription drug Copay and Deductible.

Step Therapy Requirements

For certain prescription drugs to be covered, the Plan requires covered individuals with certain conditions – including high blood pressure, nasal allergies or acid reflux – to try effective and more affordable prescription drugs first before “stepping up” to more expensive drugs.

  • Step 1 drugs – These front-line drugs are generic and sometimes lower-cost brand name drugs that have generally proven to be safe, effective and affordable. In most cases you should try these drugs first because they usually provide the
    same health benefit as a more expensive drug, at a lower cost to you and the Plan.
  • Step 2 and Step 3 drugs – Second-line drugs are brand name alternative drugs that generally are necessary for only a small number of patients for whom front-line drugs have failed. Third-line drugs are the most expensive option and have
    not shown greater clinical efficacy than lowercost drugs.

The Plan’s step therapy requirements have been developed and are updated regularly under the guidance and direction of licensed Physicians, pharmacists and other medical experts. Together with Express Scripts, they review the most current research on thousands of drugs tested and approved by the FDA for safety and effectiveness.

Only some medications are subject to the step therapy requirements, and the prescription drugs that are may change from time to time. Your pharmacist can tell you if your prescription requires step therapy. Or, at any time you can find out yourself by logging in to www.express-scripts.com and clicking “Price a Medication.”

With step therapy, more expensive brand-name drugs are usually covered as second-line alternative drugs if any of the following applies:

  • You have already tried the generic drugs covered in the step therapy program and they were unsuccessful.
  • You cannot take a specific generic drug (for example, because of a documented allergy).
  • Your Physician demonstrates, for medical reasons, that you need a brand-name drug.

If one of these situations applies to you, your Physician may request an override from Express Scripts, allowing you to take a second-line prescription drug. If the override is approved, you will pay the appropriate Copay for the drug.

Important Note About Coverage of Compound Medications

Coverage limits apply to compound medications. The Plan will only reimburse the cost of the active main ingredient, minus the Copay. In addition, if one ingredient is a non-covered item, the compound claim will be denied.

If your Physician’s request for an override is denied, you may follow the appeals process. If you choose not to appeal or your appeal is denied, you can talk to your Physician again about prescribing one of the front-line drugs covered by the step therapy program. Or you can choose to pay the full price for the drug.

Compound Medications

Compound medications are custom-made or mixed by a pharmacy based on a Physician’s prescription. Compound medications usually include more than one ingredient. At a participating retail pharmacy, you will pay your retail Copay for compound medications if the pharmacist submits a Claim electronically. In other cases, you must submit a Claim for reimbursement to Express Scripts, which must be accompanied by an itemized list of the ingredients with their full 11-digit National Drug Code (NDC) number(s) for the Claim to be processed.

Growth Hormones

Growth hormones are considered specialty medications and are covered only when purchased through Accredo. They also require prior authorization from Express Scripts before filling your first prescription. Growth hormones are not covered
for familial short stature, constitutional growth delay or for non-FDA-approved uses such as anti-aging programs or athletic enhancement.

Male Erectile Dysfunction Drugs

Prescriptions for male erectile dysfunction drugs, including but not limited to, Cialis, Levitra and Viagra, are covered only when there is an underlying medical condition, such as diabetes or a prior prostate surgery, that necessitates treatment with these medications. Prescriptions are limited to six pills of any combination of these drugs in a 30-day period. These medications require pre-authorization from the Plan, and you may contact the Plan for a list of the information needed to complete this process.

Alternatively, you may fill your first prescription at a participating pharmacy with your Express Scripts prescription drug card and pay 100% of the discounted price for the prescription. Send your original pharmacy receipt to the Plan, along with a letter from your Physician confirming your underlying medical condition to be treated and your medical records, for review. If the prescription is determined to be Medically Necessary, the Plan will forward the Claim to Express Scripts for reimbursement at 100% minus the prescription drug Copay, subject to the prescription drug Deductible.

If you use a non-participating pharmacy, your first Claim should be filed with the Plan as outlined above. If the prescription is determined to be Medically Necessary, you will be reimbursed the amount that would have been paid if you had used a participating pharmacy. You are responsible for the remainder of the bill.

After Medical Necessity is determined, subsequent prescriptions may be filled in the usual way by paying the prescription drug Copay at participating pharmacies. For non-participating pharmacies, Claims should be submitted to Express Scripts.

Infertility Drugs Prescribed for Non-Infertility Conditions

Certain medications commonly used to treat infertility may also be prescribed for conditions unrelated to infertility. In these cases, you should follow the procedures for pre-authorization and filing a Claim as outlined under “Male Erectile Dysfunction Drugs.”

Sleep Aids

Prescriptions for sleep-aid therapy, such as Ambien or Lunesta, are limited to quantities sufficient to treat 15 days per month. If you require medication in excess of this amount, you must obtain a preauthorization from the Plan. Contact the Plan for a list of the information needed to complete the pre-authorization.

Smoking Deterrents

Medications used to help you stop smoking, such as buproprion and Chantix, are not covered unless you are enrolled in the Quit for Life® Program. If you are enrolled in the program, up to eight weeks of medication will be provided at no cost to you. An additional four weeks of therapy may be provided if necessary. Optum, which administers the Quit for Life® Program, will coordinate with Express Scripts so that you may receive these medications.

Generic Drugs

Minimize your out-of-pocket costs by choosing generic equivalent drugs whenever possible. If you are prescribed a drug for which a generic equivalent is available, you will generally pay much less out-of-pocket if you purchase the generic equivalent instead of the brand name drug. The FDA requires that generic equivalent medications have the same active ingredients with the same quality, safety and effectiveness as their brand name counterparts.

Prescription Drug Coverage Through Your Medical Benefits

Prescription drug coverage is provided under the medical benefits in the following circumstances:

  • This Plan is not your primary plan, and your primary plan includes prescription drug coverage.
  • You have a prescription for an over-the-counter medication that appears on the list of ACA preventive services (see below):
    • Aspirin to prevent cardiovascular disease (men: age 45 – 79; women: age 55 – 79);
    • FDA-approved contraceptives for women;
    • Folic acid supplements for women who may become pregnant; or
    • Iron supplements for children 6 to 12 months at risk for anemia.

Prescriptions for over-the-counter medications on the list of preventive services are not subject to the medical Deductible or Coinsurance and will be paid at 100% of the Plan’s Allowance. Other prescriptions and supplies that are processed under the medical benefits will be paid at the out-of-network level of benefits, subject to the out-of-network medical Deductible and Coinsurance.

Express Scripts does not process secondary prescription drug Claims or Claims for over-thecounter medications. To receive reimbursement for these Claims, submit a copy of the drug bill to the Plan. If you have primary prescription drug coverage under another plan, you must also submit that plan’s Explanation of Benefits (EOB) form.

The drug bill must include the prescription number, name of the patient, name of the Physician, quantity filled and strength of medication. Credit card vouchers, cash receipts or canceled checks may not be substituted for bills to process drug Claims. The Plan reserves the right to request original receipts for drug purchases.

Offset of Future Benefit Reimbursements Due to Audits

If you owe the Plan money due to any audit findings by the Contribution Compliance or Participant Eligibility departments, you or your Dependents are not eligible to use the Express Scripts retail or home delivery programs until the balance due is paid in full. You will need to submit prescription charges as outlined previously under “Prescription Drug Coverage Through Your Medical Benefits.” You will be notified as soon as the Plan has recovered the entire amount that you owe, irrespective of the source of recovery, at which point you may resume regular prescription drug coverage through Express Scripts (both retail and home delivery).

Questions

If you need help or have any questions about your prescription drug program, you can call the Plan or contact Express Scripts by visiting www.expressscripts.com or calling (800) 903-4728.

Non-Covered Prescription Drug Expenses

The Plan’s prescription drug benefits are designed to cover those prescriptions and medicines that, under state or federal law, require a Physician’s prescription. However, the Plan reserves the right to restrict prescription drug coverage to one retail network pharmacy or to deny coverage for individual drugs. If a restriction is imposed, home delivery is not available as an option. The following items are not covered:

  • Anti-obesity preparations.
  • Any prescription refilled in excess of the number of refills specified by the Physician or any refill dispensed after one year from the Physician’s original order.
  • Charges for the administration or injection of any drug.
  • Condoms.
  • Contraceptive jellies, creams, foams, implants, IUDs or injections. (These are covered under the medical benefits if FDA-approved and prescribed by your Physician.)
  • Dehydroepiandrosterone (DHEA).
  • Drugs whose sole purpose is to promote or stimulate hair growth (i.e., Rogaine, Propecia) or drugs for cosmetic purposes (i.e., Renova).
  • Drugs not approved by the FDA for the treatment rendered.
  • Fluoride products (except for children whose water source does not contain fluoride).
  • Glucowatch products (covered under the medical benefits).
  • Homeopathic medications, both over-the-counter and Federal Legend (i.e. drugs that, under Federal law, may only be dispensed with a Physician’s prescription).
  • Infertility drugs, except when approved by the Plan for the treatment of non-infertility conditions.
  • Insulin pumps (covered under the medical benefits).
  • Medication which is 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, 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.
  • Non-Formulary drugs.
  • Non-sedating antihistamines (NSAs) such as Allegra, Clarinex, Xyzal and Zyrtec, except for coverage for generic Zyrtec 5 mg chewable tablets and generic Zyrtec syrup to patients age six or younger.
  • Relenza for children age six or younger.
  • Sleep aids such as Ambien and Lunesta in excess of a quantity sufficient to treat 15 days per month. Medication in excess of this amount requires prior authorization for possible approval of extended benefits.
  • Smoking deterrents, unless enrolled in the Quit for Life® Program.
  • Therapeutic devices or appliances.
  • Yohimbine.
  • Federal Legend vitamins.

For additional information, refer to the general exclusions.