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Pharmacy Benefits Program
Available only in
Sound Harbor Elite, Essential Plus and The Healthy Investor™
Individual/Family HSA Plan (if choosing prescription drug coverage)
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Three-Tier System |
Pharmacy
benefits for the Sound Harbor Elite plan are based on a three-tier system which covers drugs at
different copayment amounts. The three-tier system is based on Tier 1,
Tier 2 or Tier 3 drugs described below. The pharmacy benefit for the Essential
Plus plan covers only Tier 1 drugs (no Tier 2 or 3). If choosing prescription drug
coverage with The Healthy Investor™
Individual/Family HSA plan, Tier 1, Tier 2 and Tier 3
prescriptions are paid at 80% after satisfying the annual deductible.
The maximum benefit per person, per calendar year is $2,000.
The
Sound Harbor Elite plan includes a $200 deductible for Tier 2 and 3
drugs combined. This deductible is separate from the $1,000 medical
deductible.
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Following
are the copayment amounts for each tier:
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- Tier
1 (generic drug): $10 for Sound Harbor Elite plan; $15 for Essential
Plus
- Tier 2 (preferred
brand-name drug): 50% with $40 minimum copay
- Tier 3 (non-preferred
brand-name drug): 50% with $40 minimum copay
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Filling
Your Prescription |
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MedImpact,
a Pharmacy Benefits Management (PBM) company, administers the KPS
pharmacy program. Filling a prescription is easy! Just follow the
instructions below:
1. Present your KPS ID Card to a
participating MedImpact pharmacy
2. Pay the required copayment, depending on the prescribed drug.
3. The Pharmacist will fill your prescription and bill MedImpact for
the balance. You don't
have to fill out any forms or ask for
reimbursement.
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Description of
Prescription Tiers |
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More
Information About the KPS Pharmacy Benefit |
Copayments:
Generic drugs are Tier 1. Single-source, brand drugs listed in the Drug List are Tier 2.
Single-source, brand drugs not listed are Tier 3 drugs. You pay the lowest copay for Tier 1 drugs. You pay
a higher
copay for Tier 2 drugs, and you pay the highest copay for Tier 3 drugs. If
the minimum copay amount for a Tier 3 drug is greater than the cost of the
drug, you are responsible only for the cost of the drug.
When available, FDA-approved generic equivalents are to be used in all
situations. Certain drug products with complex pharmacokinetics or a narrow
therapeutic index are exempt from mandatory generic substitution. These
drugs include: thyroid, Synthroid, Levothroid, Coumadin, Dilantin, insulins,
Lanoxin, Tegretol, Premarin and Neoral.
Unless your
doctor indicates that your prescription should be 'dispensed as written'
(DAW), your prescription will be filled using a generic equivalent drug. If
you specifically request a brand drug rather than its generic equivalent,
you may be responsible for paying the difference between the covered cost of
the brand drug vs. the generic drug, plus any applicable copay.
Diabetic Supplies: Diabetic supplies listed on the
KPS Prescription Drug List (Drug List) are covered at a Tier 1 copay.
There is no copay for any blood glucose meter included on the Drug List.
Copays do apply to blood glucose meters which are not on the Drug
List.
Coverage for blood glucose meters is limited to one per calendar year. If
your plan does not include prescription drug benefits, or if
you are purchasing a diabetic supply which is not on the Drug List, you may
submit claims for payment of diabetic supplies (except insulin) as part of
your durable medical equipment (DME) benefits. Coverage of diabetic supplies
as a DME benefit is subject to your plan's deductible and coinsurance
requirements. Diabetic supplies include glucose meters and testing strips,
insulin agents, insulin syringes and lancets (see also Maintenance Drugs
and Supplies below).
Contraceptives: Over-the-counter contraceptive aids are not covered.
Prescription contraceptives, including self-injectable contraceptives, are
covered under your prescription drug benefits. Contraceptives that can only
be administered by your doctor (such as IUDs and Norplant implants) are
covered under your medical benefits. Diaphragms obtained from your doctor
are covered under your medical benefits. Diaphragms obtained from a network
pharmacy are covered under your pharmacy benefits (see also Maintenance
Drugs and Supplies below).
Maintenance Drugs and Supplies: You may obtain up to a three month
supply of the following: (a) any drug on Tier 1; (b) only drugs on Tier 2
that are listed on the Maintenance Drug List; and (c) any diabetic supply
that is listed under Tier 1 or Tier 2 (refer to Diabetic Supplies) on the
Drug List. When you obtain a
three-month supply, you may be required to pay an additional copay(s). Tier
3 drugs are excluded.
Off-Label Drugs: Off-label use means the prescribed use of a drug for
indications other than those specified by the FDA-approved labeling.
Off-label drugs are covered only if their use meets medical necessity
guidelines and if such off-label use is designated as a covered use by the
Pharmacy and Therapeutics Committee. |
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Prescription
Drug Exclusions and Coverage Limitations
Your Prescription Drug Plan does
not
cover the following items. This is not an all-inclusive list of coverage
exclusions. For a complete list of coverage exclusions for your Plan, please
refer to your Benefits Booklet.
-
Over-the-counter
(OTC) medications or other items, unless specifically included
as a benefit of your Plan.
- OTC nicotine smoking cessation
products or aids. However, the prescription smoking cessation drugs and/or
products included on the Drug List are covered if your Plan includes
Smoking Cessation benefits. Please refer to your Benefits Booklet for more
information.
- Any prescription or OTC drug
products used for cosmetic purposes.
- Drugs for the treatment of infertility and
obesity.
- Drugs for the treatment of impotence, unless
specifically included as a covered benefit under your Plan.
- Experimental drugs.
- Drugs used in an experimental manner.
- Drugs not yet approved by the FDA.
- Injectable drugs, except for Insulin or as
otherwise noted.
- Compounded Hormone Replacement Therapy drugs,
which have not been approved by the FDA and that are not manufactured by
a recognized drug company.
No coverage is provided for the replacement of lost or stolen medication.
No coverage is provided if your doctor does not obtain prior authorization
from MedImpact for those drugs which require authorization.
You must have your prescription filled by a
network pharmacy
except in the case of accidental injury or medical emergency.
RESTRICTIONS: If the notation PA appears after the drug name on the
drug list, you must have your doctor call MedImpact Customer Service at
1-800-788-2949 to obtain authorization before you have your prescription
filled.
Certain drugs have applicable age restrictions and/or quantity restrictions.
For more information regarding quantity and age restrictions, please check
the
drug list
or call MedImpact Customer Service.
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Important
Information About This Benefit Summary |
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This
is a brief summary of benefits; it is not a contract or a certificate of
coverage. The complete terms of coverage are determined by the carrier's
contract. While we have accurately represented the information in this
Benefit Summary as of the time it was published, should any discrepancies
exist between this Benefit Summary and the carrier's contract, the carrier's
contract shall prevail. Please refer to the carrier's contract for a
complete statement of benefits including waiting periods, limitations and
exclusions.
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