Outpatient prescription drug rider

HEALTH ALLIANCE HMO
PRESCRIPTION DRUG RIDER
BENEFIT

Health Alliance administers pharmacy benefits through a national pharmacy benefit manager. Many
independent pharmacies and most national chains are Participating pharmacies. To find out if a pharmacy
is a Participating pharmacy, call the Customer Service Department at the number listed on the back of
your Member Identification Card. You must present your Member Identification Card for each
prescription purchase. Your card contains information needed to process your prescription. The
pharmacist will ask you to pay your prescription Copayment or Coinsurance at the time it is filled. If you
do not present your Member Identification Card, you may be asked to pay the full retail price of your
prescription. To request reimbursement you may submit your itemized receipt, along with the requested
information noted on it, to the pharmacy benefit manager’s address noted on the back of your Member
Identification Card.
Prescription drugs obtained at a Participating pharmacy when prescribed by a Participating Physician,
hereinafter referred to as Physician for purposes of this Rider, in connection with Medically Necessary
services are covered for Members subject to the following terms, conditions and limitations.

Prescription Drugs obtained from a non-participating pharmacy in conjunction with emergency services
are covered subject to the terms, conditions and limitations listed below.
PREAUTHORIZATION
Some prescription drugs require Preauthorization from Health Alliance and certain criteria to be met by
you. Drugs that require Preauthorization are noted on the prescription drug formulary.
Newly released prescription drugs require Preauthorization for at least six months from the date of launch
until the drugs have undergone review by the Health Alliance Pharmacy and Therapeutics Committee.
Therapeutic classes of prescription drugs and injectables that require Preauthorization include, but are not
limited to: antifungals, NSAID analgesics (COX 2 inhibitors), leukotriene inhibitors (respiratory), proton
pump inhibitors (gastroesophageal reflux disease/ulcers), non-sedating antihistamines, gastrointestinal
agents (irritable bowel syndrome), antilipidemics (liver disease), ophthalmics and drugs for the treatment
of diabetes, rosacea acne, depression and emesis. Some prescription drugs require Preauthorization after
the trial and failure of other medications in the same therapeutic class.
Your Physician must contact Health Alliance to obtain Preauthorization. Preauthorization can be verified
by calling Customer Service at the number listed on the back of your Member Identification Card. If
Preauthorization is not obtained, Health Alliance will not provide coverage and you will be required to
pay the full cost of the drug.
PRESCRIPTION DRUG FORMULARY
Health Alliance has entered into an agreement with a third party to provide certain pharmaceutical benefit
services. This third party may contract with certain manufacturers for rebate programs. A prescription
drug formulary, which is a list of covered Tier 1, Tier 2 and Tier 3 drugs and specialty prescription drugs,
has been developed by Health Alliance. The drugs listed in the Health Alliance formulary are reviewed
and revised periodically by the Health Alliance Pharmacy and Therapeutics Committee. Prescription
drugs may be moved between tiers, as new drugs may be added to a tier or an existing drug may be
removed from a tier during the Plan Year, however the formulary, as purchased by the Group, will remain
intact during the Plan Year.
To access the most up-to-date version of our Standard Drug list, visit the Members or Visitors section of
our website www.healthalliance.org and choose “Standard Drug List” from the left-hand menu. Some
plan’s pharmacy benefits may differ from this list. Upon request, Health Alliance will provide you with
information as to whether a prescription drug is included in the formulary and whether the drug will be
covered at the Tier 1, Tier 2 or Tier 3 or specialty prescription drug Copayment or Coinsurance.
OUTPATIENT PRESCRIPTION DRUGS COVERAGE AND DISPENSING LIMITATIONS

 Outpatient prescription drugs and diabetic supplies are subject to any applicable limitations specified in the Maximums/Deductibles/Limitations section on the Description of Coverage. Copayments or Coinsurance for Outpatient prescription drugs and diabetic supplies apply to any applicable Plan Year Outpatient Prescription Drug Out-of-Pocket Maximum limit specified on the Description of Coverage. Initial prescriptions and prescription refills are limited to the maximum supply specified in the Outpatient Prescription Drugs section on the Description of Coverage.  You pay the lesser of the Participating pharmacy’s regular charge for the drug or the Copayment or Coinsurance specified in the Outpatient Prescription Drugs section on the Description of Coverage for each initial prescription or prescription refill.  The following diabetic supplies are covered and will be subject to the Copayment or Coinsurance specified in the Outpatient Prescription Drugs section on the Description of Coverage: glucagon emergency kits, insulin, syringes and needles, oral legend agents for controlling blood sugar, and test strips for glucose monitors.  Coverage will be provided for prescription contraceptives prescribed for the purpose of preventing conception, and which are approved by the United States Food and Drug Administration (FDA), or generic equivalents of contraceptives approved as substitutable by the FDA. Prescription contraceptives will be subject to the Copayment or Coinsurance specified in the Outpatient Prescription Drugs section on the Description of Coverage.  Most, but not all, generic drugs (as defined by National DataBank/claims processors database) will be dispensed under the Tier 1 Copayment or Coinsurance when they exist and are available and allowable by applicable State or federal law.  If you or your Physician requests a brand name drug when a generic exists, you pay the Tier 1 Copayment or Coinsurance, plus the difference in cost between the brand name drug and the generic drug. (See asterisk (*) below)  If a Tier 2 or Tier 3drug is prescribed and a generic does not exist, you pay the Tier 2 or Tier 3 Copayment or Coinsurance. (See asterisk (*) below)  Injectable syringes are covered when the injectable drug is covered.  Prescription drugs for the treatment of male erectile dysfunction that are approved by the Health Alliance Pharmacy and Therapeutics Committee are covered. Examples of covered drugs include, but are not limited to: Viagra®, intracavernous vasoactive drug injections (Caverject® and Edex®) and intraurethral treatment (MUSE®). Treatment is limited to four doses of one drug per month.  A limited number of over-the-counter (OTC) medications are covered. A prescription is required from your Physician for covered OTC products and either the Tier 1 or Tier 2 Copayment or Coinsurance applies.  If you are enrolled in the smoking cessation program, smoking cessation pharmacological therapy, as defined by the Health Alliance formulary is covered.  For a 90-day supply of maintenance medications obtained through the mail-order pharmacy service you pay 2.75 Copayments instead of the three Copayments you would pay for a 90-day supply indicated on the Description of Coverage. For mail-order prescription drugs, the prescription, an order form and the Copayment or Coinsurance must be mailed to the mail-order pharmacy service. The mail-order pharmacy is required by law to fill the prescription with the amount ordered only, however your mail-order Copayment or Coinsurance still applies regardless of the amount dispensed. It is recommended that prescriptions for less than a 90-day supply be filled at an Outpatient Participating pharmacy.  A 90-day supply of maintenance medications at the rate of 2.75 Copayments instead of three Copayments may also be obtained at certain Participating retail pharmacies. For a list of these Participating retail pharmacies, please call our Pharmacy Department at 1-800-851-3379, extension 8078.
* If a Tier 3 drug is determined to be Medically Necessary by your Physician and Health Alliance, you
pay the Tier 2 Copayment or Coinsurance.

OUTPATIENT CONTRACEPTIVE SERVICES/DEVICES/INJECTABLES

Outpatient Contraceptive Services
 Medically Necessary consultations, examinations, procedures and medical services provided in a Physician’s office and related to the use of contraceptive methods to prevent an unintended pregnancy are covered when services are rendered by or under the supervision of a Participating Physician. Services are subject to the office visit Copayment or Coinsurance specified on the Description of Coverage.
Prescription Contraceptive Devices/Injectables
 Prescription contraceptive devices/injectables include, but are not limited to, injectable prescription drugs (DepoProvera®), implants (Norplant®), IUDs and diaphragms. Prescription contraceptive devices/injectables are subject to the Prescription Contraceptive Devices/Injectables Coinsurance amount specified on the Description of Coverage.  Prescription contraceptive devices/injectables provided on an Outpatient basis in a Physician’s office are covered when services are rendered by or under the supervision of a Participating Physician.  Injectable syringes are covered when the injectable drug is covered.  Prescription contraceptive devices/injectables do not apply to the Medical Out-of-Pocket
SPECIALTY PRESCRIPTION DRUGS
Specialty Prescription Drugs are defined as any prescription drug, regardless of dosage form, which
requires at least one of the following in order to provide optimal patient outcomes and is identified as a
Specialty Prescription Drug on the Health Alliance drug formulary: (1) Specialized procurement handling;
distribution, or is administered in a specialized fashion; (2) Complex benefit review to determine
coverage; (3) Complex medical management; or (4) FDA mandated or evidence-based, medical-guideline
determined, comprehensive patient and/or physician education.

Specialty Prescription Drugs are available from a specialty pharmacy vendor. Coverage is subject to a
prior written order by your Physician. You pay the Specialty Prescription Drugs Copayment or
Coinsurance amount specified in the Outpatient Prescription Drugs section of the Description of
Coverage. Specialty Prescription Drugs are subject to any applicable Specialty Prescription Drug
limitations specified in the Maximums/Deductibles/Limitations section on the Description of Coverage.
Copayments or Coinsurance for Specialty Prescription Drugs apply to any applicable Plan Year Specialty
Prescription Drug Out-of-Pocket Maximum limit specified in the Maximums/Deductibles/Limitations
section on the Description of Coverage.
PRESCRIPTION DRUGS NOT COVERED

 Prescription drugs prescribed by a non-participating Physician or obtained at a non-participating pharmacy, unless obtained for treatment of an Emergency Medical Condition.  Prescription drugs for the treatment of a dental condition.  Prescription drugs for the treatment of infertility, unless otherwise covered under an Infertility Prescription Drug Rider attached to the Policy.  Non-prescription drugs or medicines are not covered, except for covered diabetic supplies, injectable syringes for covered injectable drugs and a limited number of over-the-counter (OTC) medications as stated above.  When a medication is available both by prescription only (federal legend) and as an OTC product,  Prescription drugs which are not considered to be Medically Necessary, in accordance with accepted medical and surgical practices and standards approved by Health Alliance, including but not limited to: BOTOX®, psoralens, tretinoin and oral antifungal agents for cosmetic use, anorexiants or weight loss medications, anabolic steroids, oral fluoride preparations and hair removal or hair growth promoting medications.  Growth hormones for idiopathic short stature.  Devices of any type, other than prescription contraceptive devices, even if such devices may require a prescription, including but not limited to: therapeutic devices, artificial appliances, support garments, bandages, etc.  Any drug labeled, “Caution—Limited by Federal Law to Investigational Use,” or experimental or other drugs which are prescribed for unapproved uses. Prescription Drugs for cancer treatment are covered if the drug is approved by the FDA and must be recognized for the treatment of the specific type of cancer for which the drug has been prescribed in any one of the following established reference compendia: (1) the American Medical Association Drug Evaluations; (2) the American Hospital Preferred Service Drug Information; or (3) the United States Pharmacopeia Drug Information; or if not in the compendia, recommended for that particular type of cancer in formal clinical studies, the results of which have been published in at least two peer-reviewed professional medical journals published in the United States or Great Britain.  Prescription drugs for which the cost is recoverable under any Workers’ Compensation or Occupational Disease Law or any state or governmental agency, or any medication furnished by any other Drug or Medical Service for which there is no charge to you.  Any charge for the administration of a drug.  Replacement of lost, destroyed or stolen medication and any supplies for convenience.  Prescriptions refilled before 75 percent of the previously dispensed supply should have been  Any drug determined to be abused or otherwise misused by you.  Any prescription drug purchased or imported from outside of the United States of America.  Any prescription drug received outside of the United States of America, unless received as part of DRUG LIMITATIONS

Certain prescription drugs may be subject to drug limitations based on FDA-approved dosage
recommendations and the drug manufacturer’s package size. The purpose of these limitations is to
encourage safe and cost-effective use of drug therapies.


Except as amended by this Rider, all terms and conditions of the Health Alliance HMO Policy to which
this Rider is attached shall remain in full force and effect.

Source: http://hr.siu.edu/_common/documents/amendments/prescription.pdf