What is Covered? The OU Plan covers drugs, biologicals and compounded prescriptions that can be dispensed only pursuant to a prescription and that are required by law to bear the legend: “Caution – Federal Law prohibits dispensing without a prescription.” The drug or medication must be prescribed by a Professional Provider, and approved by the FDA for the treatment or for specific diagnosis or condition. The drug must also be Medically Necessary treatment of the condition for which the drug is prescribed, and not Experimental and Investigational as defined in this Plan, unless otherwise required pursuant to an external appeal. Insulin and oral agents for controlling blood sugar are provided through the prescription drug program, as are other diabetic supplies. (Please see Section 9 for additional details on diabetic supplies furnished through the prescription drug program.)

Prescription Drugs include contraceptive drugs and devices as well as Medically Necessary enteral formulas for which a provider has issued a written order. The written order must state that the enteral formula is Medically Necessary and has been proven effective as a disease-specific treatment regimen for those individuals who are or will become malnourished or suffer from disorders, which if left untreated, cause chronic disability, mental retardation or death. The Plan also pays for modified solid food products for the treatment of certain inherited diseases of amino acid or organic acid metabolism, when provided pursuant to a written order. However, our coverage for modified solid food products is limited to $2,500 in a calendar year.

Generic equivalents of prescribed drugs will be provided unless specifically prohibited by the prescribing physician. If you choose to obtain a brand name drug when a generic equivalent is available, you will be responsible to pay the excess charges.

What is Not Covered? In addition to any exclusions found elsewhere in this Plan, benefits are not provided for the following:

• Drugs not requiring a written prescription (except insulin);
• Drugs that have over-the-counter equivalents (i.e., the same drug), except as otherwise provided;
• Artificial appliances, therapeutic devices, hypodermic needles and similar devices (except for insulin injection, bone density devices and contraceptive devices);
• Administration of injection drugs;
• Appetite suppressants, unless they are determined to be Medically Necessary to diagnose or treat a Covered Person’s medical condition (in no case will over-the-counter appetite suppressants be a covered benefit);
• Vitamins or any herbal products (other than those requiring a prescription);
• Drugs that are prescribed or dispensed for cosmetic purposes and that are not required to diagnose or treat a Covered Person’s documented medical condition. A drug that may be used both for cosmetic purposes, and for medical purposes, such as Botox, will not be excluded if used for a medical purpose; however, it will not be covered if used solely to, for example, improve one’s appearance. Contact the case management consultant if you have any questions
  concerning the coverage of drugs used for cosmetic purposes. Examples of drugs that we often determine not to be Medically Necessary include those prescribed or dispensed for hair growth stimulants or removing wrinkles;
• Immunization agents, biological sera, blood or blood plasma;
• Drugs or devices used to improve sexual performance or stimulation, unless they are determined to be Medically Necessary to diagnose or treat a Covered Person’s medical condition.
• Drugs dispensed to patients in Facilities, unless the institution does not include services for drugs;
• Drugs for which payment is made under Federal or State law, such as Workers’ Compensation or no-fault insurance;
• Drugs that are determined to be Experimental or Investigational (unless otherwise required to be covered pursuant to external review).

How the Program Works. If you purchase drugs at a participating (in-network) pharmacy or through the mail order pharmacy, your co-payments depend upon the category of the drug purchased. Generic drugs cost the least, while preferred drugs and non-preferred drugs are more expensive. For a list of preferred drugs (PDL), see the pharmacy benefit manager’s web site listed in Appendix A.

Using the Mail Order Pharmacy. If you choose, you may order a 90-day supply of long term or maintenance drugs through the mail order pharmacy. Three refills of mail order drugs may be obtained under each prescription order. Your co-pays will be less for mail order drugs than for drugs you refill monthly at the drug store. Once you have had a prescription filled for three months, you are eligible to order additional refills through the mail order pharmacy. Drugs purchased in this manner will be sent directly to your home, postage paid. Forms for the mail order pharmacy are available from your Employer’s health plan administrator. The table below shows your co-pay for drugs, depending on the type of drug (generic, preferred or nonpreferred) and whether you obtain the drug at a retail drug store or through the mail order pharmacy.

Where Drug Purchased	Your Co-Payment Amount
Purchased at Participating Pharmacy	For Generic Drugs For Preferred Drugs (PDL) For Non-PDL Brands (As designated by the Plan’s PBMPDL Formulary)	$5 co-payment per prescription (34 day maximum supply) $20 co-payment per prescription (34 day maximum supply) $40 co-payment per prescription (34 day maximum supply)
Purchased through Mail Order Pharmacy Program	For Generic Drugs For Preferred Drugs (PDL) For Non-PDL Brands (As designated by the Plan’s PBMPDL Formulary)	$7.50 co-payment per prescription (90 day maximum supply) $30 co-payment per prescription (90 day maximum supply) $60 co-payment per prescription (90 day maximum supply)

Using Non-Participating Pharmacies. If you fill your prescription at a non-participating (out-of-network) pharmacy, you will have to pay the retail price of the drug and then file a claim for reimbursement with the pharmacy benefit manager (PBM). You will be reimbursed the in-network pharmacy discount rate, minus the applicable in-network co-payment, and your cost will probably be higher than it would be if you went to a participating pharmacy. You may obtain claim forms from your Employer or Claims Administrator.

Drugs that Require Prior Authorization. Certain drugs that may be prescribed by your doctor require that the pharmacist contact the pharmacy benefit manager for verification of coverage. These drugs include those used to treat migraines, obesity, ADD, narcolepsy and arthritis. The pharmacist will let your physician know if there are any authorization or limitation requirements on the prescribed drugs.