Cm-704-67315-pc1270-00The Reta Trust
Pharmacy Schedule of Benefits for 3-Tier Formulary
Summary of Benefits
Retail Pharmacy Copayment
(per Prescription Unit or up to 30 days)
Mail-Service Pharmacy Copayment
(up to 3 Prescription Units or up to 90 days)
Specialty Pharmacy Copayment (up to 30 days)
Market Priced Drugs
See below description
** There is a $2000.00 max out of pocket benefit per participant. Once you meet the out of
pocket maximum your copay will be $0** Please Note: Maximum Out of Pocket Benefit resets
every plan year on July 1.
What is my Schedule of Benefits?
This Schedule of Benefits provides specific details about your Prescription Drug Benefit, as well as its exclusions and
How do I use my Prescription Drug Benefit?
Your Prescription Drug Benefit helps to cover the cost for some of the medications prescribed by a licensed Physician.
Using your benefit is simple.
Present your prescription and OptumRx ID card at any OptumRx Participating Pharmacy. Pay the Copayment for a Prescription Unit or its retail cost, whichever is less. Receive your medication.
What do I pay when I fill a prescription?
You will pay only a Copayment when filling a prescription at an OptumRx Participating Pharmacy. You will pay a
Copayment every time a prescription is filled. Your benefits are as follows: When you fill or refill a prescription for a generic medication, your Copayment is $10 for a 30-day supply (excluding maintenance medications). When you fill or refill a prescription for a Formulary brand-name medication, your Copayment is 30% for a 30-day supply (excluding maintenance medications). When you fill or refill a prescription for a Non-Formulary brand-name medication, your Copayment is 50% for a 30-day supply (excluding maintenance medications).
Preferred Mail Service for Maintenance Medications - For maintenance medications you will be able to receive 3
refills at a retail pharmacy for the customary retail copayment ($10 generic, 30% Formulary, 50% Non-Formulary). On
the 4th refill you can chose to either continue to use your retail pharmacy and the retail copayment will be doubled for a
30 day supply ($20 generic, and remain at 30% for Formulary brand, and 50% for Non-Formulary brand), or you can chose to utilize the mail service pharmacy and pay the mail service copayment ($20 generic, 30% Formulary Brand, 50% Non-Formulary Brand) for up to a 90 day supply.
3 Tier Revised 4/28/2014 Market Priced Drugs: Reta Value Options
Many brand-name medications have generics, brands, or over-the-counter (OTC) equivalents available that cost less and
are FDA-approved drugs with similar effectives. Market priced drugs are: The most cost-effective FDA-approved drugs (generics, brands or OTC equivalents) that provide a therapeutically equivalent result, based on available medical evidence. Designated as the formulary drug for each therapeutic category (a therapeutic category is a group of drugs that treat a given diagnosis, such as statins used to treat high cholesterol).
How Market-Based Pricing Works
Under Market-Based Pricing, you can choose to continue to use a drug that has a lower-priced, formulary drug equivalent, but Reta will pay only the amount it would have paid for the therapeutically similar drug that costs less (the market-priced drug). You will pay the difference between the full market price of your prescription and the full market price of the lowest cost therapeutic alternative plus the copay for the lowest cost therapeutic alternative. The Plan's contribution for all therapeutic alternatives is based on what the Plan currently contributes to the lowest cost alternative. The Plan does not provide a greater subsidy or benefit for more expensive, therapeutically similar, Reta partners with OptumRx and DRX to deliver Market-Based Pricing. DRX/DestinationRx built and owns the most comprehensive drug therapy and price comparison database available. Using this information, you'll be able to work more effectively with your doctor to make informed decisions about medications. All the drug options DestinationRx covers have been approved by the Food and Drug Administration (FDA) for safety. Market prices are subject to periodic updates as the cost of these drugs changes. To help you keep track of the drug prices and to identify lower-cost options, go to:
When I fill a prescription, how much medication do I receive?
For a single Copayment, Members receive either one Prescription Unit or up to a 30-day supply of a drug. If you use the OptumRx Mail Service Pharmacy program, you will receive three Prescription Units or up to a 90- day supply of maintenance medications.
What else do I need to know?
You should become familiar with OptumRx' prescription drug Formulary. Any medication not on the Formulary you will pay the higher non-formulary copayment. For more information on the Formulary, please visit It is possible to buy a brand-name drug in place of a generic equivalent, even though the generic drug is the only one listed on our Formulary. Your cost, however, will be higher (Non-Formulary copayment). For more information, please continue to "Medications Covered by Your Benefit" and read the description for Generic ADDITIONAL INFORMATION
Medications Covered by Your Benefit
The following medications are included in the OptumRx managed Formulary and are available to your Physician.
Federal Legend Drugs: Any medicinal substance which bears the legend: "Caution: Federal law prohibits dispensing without a prescription." State Restricted Drugs: Any medicinal substance that may be dispensed by prescription only according to state Generic Drugs: Comparable generic drugs may be substituted for brand-name drugs. For the purposes of determining coverage, the following items are considered prescription drug benefits: glucagon, insulin, insulin syringes, blood glucose test strips, lancets, inhaler extender devices, urine test strips and anaphylaxis prevention kits (including, but not limited to, EpiPen¨, Ana-Kits¨ and Ana-Guard¨). Injectable drugs (except as listed under "Exclusions and Limitations"). 3 Tier Revised 4/28/2014 Selective Preauthorization
Your covered services include certain medications that require the covered person go through a preauthorization or step
therapy process. Preauthorization means that certain select medications will not be covered until one or more formulary alternatives or "first-line" drugs have been tried first. OptumRx reserves the right to preauthorize, institute step therapy and/or limit the quantity of any prescription to ensure that the following coverage criteria are met: (1) the prescription is for the treatment of a medical condition (2) there is sufficient evidence to draw conclusions about the effects of the prescription on the medical condition being treated and on the health outcome of the member (3) the expected beneficial effects of the prescription outweigh the expected harmful effects and (4) the prescription represents the most cost-effective method to treat the medical condition Exclusions and Limitations
While the Prescription Drug Benefit covers most medications, there are some that are not covered:
Drugs or medicines purchased and received prior to the Member's effective date or subsequent to the Member's Therapeutic devices or appliances, including hypodermic needles, syringes (except insulin syringes), support garments and other nonmedicinal substances. All nonprescription (over-the-counter) contraceptive jellies, ointments, foams or devices. Contraceptives prescribed for birth control Medications to be taken or administered to the eligible Member while a patient in a hospital, rest home, nursing home, sanitarium, etc. Drugs or medicines delivered or administered to the Member by the prescriber or the prescriber's staff. Dietary supplements, including vitamins and fluoride supplements (except prenatal), health or beauty aids, herbal supplements and/or Alternative Medicine. Compounded Medication: Any medicinal substance that has at least one ingredient that is Federal Legend or state Restricted in a therapeutic amount. All compounded medications are subject to OptumRx' prior authorization process Medication for which the cost is recoverable under any workers' compensation or occupational disease law or any state or government agency, or medication furnished by any other drug or medical service for which no charge is made to the patient. Medication prescribed for Experimental or Investigational therapies, unless required by an external independent review panel pursuant to California Health and Safety Code Section 1370.4. For non-Food-and-Drug-Administration-approved indications, see the following exclusion. Off-Label Drug Use: Off-Label Drug Use means that the Provider has prescribed a drug approved by the Food and Drug Administration (FDA) for a use that is different than that for which the FDA approved the drug. OptumRx excludes coverage for Off-Label Drug Use, including off-label self-injectable drugs, except as described in the Subscriber Agreement and any applicable Attachments. If a drug is prescribed for Off-Label Drug Use, the drug and its administration will be covered only if it satisfies the following criteria: o The drug is approved by the FDA. o The drug is prescribed by a licensed health care professional for the treatment of a life-threatening condition or for a chronic and seriously debilitating condition. o The drug is Medically Necessary to treat the condition. o The drug has been recognized for treatment of the life-threatening or chronic and seriously debilitating condition by one of the following: The American Medical Association Drug Evaluations; The American Hospital Formulary Service Drug Information; The United States Pharmacopeia Dispensing Information; or in two articles from major peer-reviewed medical journals that present data supporting the proposed Off-Label Drug Use or Uses as generally safe and effective. o The drug is administered as part of a core medical benefit as determined by OptumRx. Nothing in this section shall prohibit OptumRx from use of a Formulary, Copayment, technology assessment panel or similar mechanism as a means for appropriately controlling the utilization of a drug that is prescribed for a use that is different from the use for which that drug has been approved for marketing by the FDA. Denial of a drug as investigational or experimental will allow the Member to use the Independent Medical Review System as defined in the medical Combined Evidence of Coverage and Disclosure Form. Medications available without a prescription (over-the-counter) or for which there is a nonprescription equivalent available, even if ordered by a Physician. 3 Tier Revised 4/28/2014 Elective or voluntary enhancement procedures, services, supplies and medications, including, but not limited to, weight loss, hair growth, athletic performance, cosmetic purposes, anti-aging and mental performance. Examples of these drugs include, but are not limited to, Penlac, Retin-A, Renova, Vaniqa, Propecia, Lustra, Xenical or Meridia. Medications dispensed by a non-Participating Pharmacy (except for prescriptions required as a result of an Emergency or Urgently Needed Service for an acute condition). Drugs prescribed by a dentist or drugs used for dental treatment. Drugs used for diagnostic purposes. Saline and irrigation solutions. MUSE suppositories. Replacement of lost, stolen or destroyed medications. OptumRx reserves the right to expand the prior authorization requirement for any drug product to assure adherence to FDA-approved indications and national practice standards. The Appeals Process
OptumRx contracts with a leading independent review organization (IRO) for the administration and determination of appeals. Your appeal will be reviewed and you will be notified in writing of the determination within 30 calendar days of OptumRx receipt of the appeal. If your appeal is denied, your written response will include the specific reason for the decision, describe the criteria or guidelines or benefit provision on which the denial decision was based, and notification that upon request the Member may obtain a copy of the actual benefit provision, guideline protocol or other similar criterion on which the denial is based. For determinations delaying, denying or modifying health care services based on a finding that the services are not Covered Services, the response will specify the provisions in the pharmacy plan documents that exclude that coverage. If you are not satisfied with the outcome of the first appeal, you may request a second appeal.
Expedited Review Appeals Process
Appeals involving an imminent and serious threat to your health including, but no limited to, severe pain or the potential
loss of life, limb or major bodily function will be immediately referred to the IRO's clinical review personnel. Expedited appeals will be reviewed and you will be notified of the determination within 72 hours from OptumRx receipt of the appeal. If your case does not meet the criteria for an expedited review, it will be reviewed under the standard appeal
Specialty Pharmacy (Injectable Medications)
OptumRx ® Specialty Pharmacy will conveniently deliver your Injectable medications to your home or physician's office, or other location of choice. And there is no charge for shipping! Your prescription drug benefit allows one grace fill at any retail pharmacy, for up to a 30-day supply each, to ensure you continue receiving your specialty medication(s) as scheduled. After that, you are required to utilize mail service for your specialty medications. Once a registered pharmacist has reviewed and verified the prescription, a Patient Care Coordinator will contact you to set up delivery and answer any questions you may have. All necessary supplies (such as syringes, alcohol swabs, Sharps containers) used with your injectable medications will be provided with your order at no additional charge. The Specialty team is available to answer your medication-related questions 7am to 9pm Central Time, Monday – Friday and 8am to 7pm Central Time Saturday – Sunday at (888) 702-8423. Pharmacists are on-call 24 hours, seven days a week. They will contact your doctor for authorization as needed. 3 Tier Revised 4/28/2014
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