MMC Benefits Handbook
Prescription Drugs
How does the Plan cover prescription drugs?
Prescription drugs are covered as follows:
Prescription drugs
There is a pharmacy network for retail and Express Scripts by Mail for mail order prescription drugs.
 
$400 Deductible Plan
$900 Deductible Plan
$1,500 Deductible Plan
$2,850 Deductible Plan
Retail Prescriptions
(30-day supply)
  • Generic
$10 copay (These amounts do not apply to the deductible)
70% coinsurance (These amounts do not apply to the deductible; minimum $10/maximum $20)
80% coinsurance after deductible
70% coinsurance after deductible
  • Formulary Brand
$30 copay (These amounts do not apply to the deductible)
70% coinsurance (These amounts do not apply to the deductible; minimum $25/maximum $50)
80% coinsurance after deductible
70% coinsurance after deductible
  • Non-Formulary Brand
$60 copay (These amounts do not apply to the deductible)
55% coinsurance (These amounts do not apply to the deductible; minimum $40/maximum $80)
80% coinsurance after deductible
70% coinsurance after deductible
Mail-order Prescriptions
(90-day supply)
  • Generic
$25 copay (These amounts do not apply to the deductible)
70% coinsurance (These amounts do not apply to the deductible; minimum $25/maximum $50)
80% coinsurance after deductible
70% coinsurance after deductible
  • Formulary Brand
$75 copay (These amounts do not apply to the deductible)
70% coinsurance (These amounts do not apply to the deductible; minimum $62.50/maximum $125)
80% coinsurance after deductible
70% coinsurance after deductible
  • Non-Formulary Brand
$150 copay (These amounts do not apply to the deductible)
55% coinsurance (These amounts do not apply to the deductible; minimum $100/maximum $200)
80% coinsurance after deductible
70% coinsurance after deductible
Does the Plan cover formulary and non-formulary brand-name prescription drugs?
The Plan covers formulary and non-formulary prescription drugs purchased via the Plan's mail order service or a participating retail pharmacy. The prescription drugs in the formulary may change.
To price medications and check formulary, visit www.express-scripts.com.
Unless your physician specifically prescribes a brand-name medication without substitution, prescriptions will be filled with the generic equivalent when allowed by state law.
Does the Plan cover generic drugs?
The Plan covers generic prescription drugs purchased via the Plan's mail order service or a participating retail pharmacy.
What happens if I buy a brand-name prescription drug when a generic drug is available?
Unless your physician specifically prescribes a brand name medicine without substitution, prescriptions will be filled with the generic equivalent when allowed by state law.
If you or your physician requests the brand-name prescription drug when a generic prescription drug is available and there is no medical reason for the brand-name prescription drug, you pay your share of the cost for the generic drug in addition to the difference between the brand-name prescription drug and generic prescription drug gross cost.
How does the Plan cover generic and brand-name contraceptive medications with no generic equivalent?
The Plan will cover certain generic and brand-name contraceptive medications with no generic equivalent at 100% in-network with no cost sharing as long as a valid prescription is submitted.
What is the Plan coverage for preventive drugs?
Preventive drugs as defined by the Patient Protection Affordable Care Act for the $400 Deductible Plan, the $900 Deductible Plan, the $1,500 Deductible Plan and $2,850 Deductible Plan are covered with no cost sharing (i.e. deductible, coinsurance, copay). Certain examples include: aspirin products, fluoride products, folic acid products, immunizations, contraceptive methods, smoking cessation products, bowel preps, primary prevention of breast cancer and statins.
If you enrolled in the $1,500 Deductible Plan or the $2,850 Deductible Plan, there are certain preventive medications that are not subject to the deductible. Certain examples include: hypertension, diabetes, asthma, and cholesterol lowering drugs.
Call Express Scripts at +1 800 987 8360 for more information about preventive drugs or log on to the Drug Pricing Tool. Follow the provided steps to access the Drug Pricing Tool.
  • Log on to express-scripts.com.
  • Login or create an account.
  • Prescriptions.
  • Price a medication.
  • Choose a pharmacy and enter drug name.
The Pharmacy Benefits Manager provides an online directory of network pharmacies available at www.express-scripts.com. You may also call the Pharmacy Benefits Manager.
Is there a mail-order program?
The Plan's mail order service allows participants to order up to a 90-day supply of prescription medication by mail for certain medications. Using the mail order service for these medications will generally cost you less than using a retail pharmacy.
If I buy more than three fills of a prescription drug at a retail pharmacy, will I have to pay more?
For all maintenance prescription drugs, after purchasing the first three fills of a prescription drug (the initial fill plus two refills) at a participating retail pharmacy, if you choose to continue to fill the prescription at a retail pharmacy, you pay 100% of the negotiated price for up to a 30-day supply for all subsequent refills.
If I purchase a specialty medication at retail, will the prescription be covered?
If a specialty medication is filled at retail, the prescription will not be covered and amounts you pay for the not covered prescription will not accumulate to the out-of-pocket maximum.
Are any prescription drugs or drug supplies subject to limitations?
You may be subject to several different types of drug management programs. These include quantity management, prior authorization and qualification by history or step therapy.
Quantity Management
To ensure safe and effective drug therapy, certain covered medications may have quantity restrictions. These quantity restrictions are based on manufacturer and/or clinically approved guidelines and are subject to periodic review and change.
Select examples of drug categories include:
  • Antiemetic agents
  • Antifungal agents
  • Cancer therapy
  • Cardiovascular agents
  • Diabetic agents
  • Diabetic devices (blood glucose meters)
  • Erectile dysfunction agents
  • Fertility agents
  • Hypnotic agents
  • Inhaler spacers
  • Migraine therapy
  • Narcotic analgesics
  • Non-narcotic analgesics
  • Rheumatological agents
  • Specialty medications
Prior Authorization
Certain medical treatments and prescription medicines need prior approval (which may include the submission of clinical information by your prescriber) before the Plan will cover them. This requirement is to ensure the treatment or medication is appropriate and effective. If you do not receive approval, you will be responsible for paying the full cost.
Select examples of drug categories include:
  • Androgens and anabolic steroids
  • Anorexiants
  • Antinarcoleptics
  • Cancer therapy
  • Dermatologicals
  • Specialty medications – require prior authorization under the Plan and are subject to quantity limitations as well
    • Examples of drug categories include: Botulinum Toxins (Botox), Growth Hormones, Hepatitis, Immune Globulins, Multiple Sclerosis, Myeloid Stimulants, Psoriasis, Pulmonary Arterial Hypertension (PAH), Rheumatoid Arthritis, RSV agents.
The drugs that require prior authorization may be modified. To obtain prior authorization for coverage ask your doctor to call Express Scripts at +1 800 753 2851. After they receive the necessary information, you and your doctor will be notified confirming whether or not coverage has been approved.
Qualification by History (Step Therapy)
Some medications require the trial of another drug and/or require certain criteria such as age, sex, or condition (determined by previous claims history) to receive coverage. In these cases, a coverage review will be required if certain criteria cannot be determined from past history.
Select examples of drug categories include:
  • Cardiovascular agents
  • COX-lI Inhibitors
  • Dermatologicals
  • Migraine therapy
  • Osteoporosis agents
  • Specialty medications
Examples of drug categories include: Erythroid Stimulant, Fertility, Growth Hormone, Hepatitis, Multiple Sclerosis, Pulmonary Arterial Hypertension (PAH) agents.
The drugs that may become subject to qualification by history rules may be modified.
Contact the Pharmacy Benefits Manager at +1 800 987 8360 for more information about any of these programs.
Are there any limitations on specialty prescription drugs?
The Accredo Recommended Days Supply Program maintains quantity limitations for certain specialty prescription drugs in accordance with FDA approval limits and to help reduce drug waste and prescription drug costs.
The first time you submit a claim for a specialty medication on this list, you will be limited to a 30-day supply for four months, even if your physician prescribed a 90-day supply. Your copayment will be prorated, so you will not be penalized for filling the prescription in 30-day supply increments instead of a 90-day supply.
An Accredo Representative will contact both you and your physician to explain why the prescription has been limited to a 30-day supply, discuss therapy and the disease state and discuss the importance of compliance.
In addition, specialty medications require prior authorization under the Plan and are subject to quantity limitations and cost caps. These limits are subject to change and are discussed above.
Certain specialty drugs which you can administer to yourself (or a caregiver may administer to you) are not covered under the medical benefit.
Contact the Pharmacy Benefits Manager at +1 800 987 8360 for more information about any of these programs.
Medical Specialty Drugs Administered by a Medical Provider
Your Plan covers certain Specialty Drugs that must be administered to you as part of a doctor's visit, home care visit, or at an outpatient Facility when they are Covered Services. This section applies when a Provider orders the Drug and a medical Provider administers it to you in a medical setting or in your home by a home infusion provider.
Precertification
Precertification is required for certain Medically Administered Specialty Drugs to help make sure proper use and guidelines for these drugs are followed. Your Provider will submit clinical information which will be reviewed for decision.
For a list of Medically Administered Specialty Drugs that need precertification, please contact your Claims Administrator. The precertification list is reviewed and updated from time to time. Including a Specialty Drug on the list does not guarantee coverage under your Plan. Your Provider may check with us to verify Specialty Drug coverage, to find out which drugs are covered under this section and if precertification is required.
If you are receiving an infused medication, certain medications may require use of the lowest cost site of care.
What prescription drugs and drug supplies are excluded from prescription drug coverage?
The following drugs and drug supplies are excluded from prescription drug coverage:
  • Over-the-counter drugs (including topical contraceptives, nicotine products, vitamins and minerals, nutritional products including enteral products and infant formulas, homeopathic products and herbal remedies). Certain drugs will be covered with a prescription under Health Care Reform.
  • Medical equipment and devices – insulin pumps, insulin pump syringes
  • Home diagnostic kits
  • All injectables (other than self-administered injectables and injectable drugs in connection with approved infertility treatment)
  • Allergy serums
  • Plasma and blood products
  • Drugs for cosmetic use
  • Prescription products with an over the counter equivalent
  • Investigational drugs, experimental use drugs, non-FDA approved drugs and compounds.
Note, you can receive the Pharmacy Benefits Manager's discounted price when you fill a prescription for a non-covered drug through the Pharmacy Benefits Manager's mail order program. You will pay 100% of the cost at the negotiated rate.
Is there a network of pharmacies?
There is a pharmacy network associated with this Plan. You must use a pharmacy in the network to receive coverage under this Plan.
The Pharmacy Benefits Manager provides an online directory of network pharmacies.
To locate an in-network retail pharmacy:
Or call Express Scripts at +1 800 987 8360 for more information.
How do I file a claim for benefits for prescription drugs?
All prescriptions filled at a participating retail pharmacy require you to provide an ID card for coverage under the Plan. You are responsible for the applicable copayment or coinsurance. Rarely will you need to file a claim with the Pharmacy Benefits Manager (one example may be a prescription filled at retail before you have received your ID card). To file a claim, contact the Pharmacy Benefits Manager.
Claim forms are available on the Pharmacy Benefits Manager's website. If you file a claim within 60 days of your effective date with the Plan, you will be reimbursed 100% of your out of pocket expense minus the appropriate coinsurance. After your 60 day grace period, you have 12 months from the date the expense was incurred to submit a claim. You are responsible for the difference between the discounted in-network price and the out-of-network price and the appropriate coinsurance.
Is there a separate ID card for the prescription drug program?
Yes, there is a separate ID card for the prescription drug program. If you are enrolled in medical coverage, you will automatically be sent a prescription drug ID card in addition to your medical plan ID card. You will be sent one additional prescription ID card if you enroll one or more family members in the program. Each ID card will list the names of all covered family members.
You may request additional ID cards directly from the Pharmacy Benefits Manager.