Benefitmovie.com

Munroe Regional Medical Center
Effective October 1, 2012

Munroe Choice, Munroe Advantage, Network Choice and Network Advantage

1-34 Day Supply 90 Day Supply
At a retail pharmacy Through Mail
Generic Drugs/Tier 1
Formulary Brand/Tier 2
Non-Formulary Brand/Tier 3

Generic Policy: If your doctor writes a prescription stating that a Generic may be dispensed, your coverage will only pay for the
generic drug. If you choose to buy the Brand name drug in this situation, you will be required to pay the Generic co-pay plus the
difference in cost between the Generic and Brand name drug. The Generic Policy does not apply if your doctor requires a brand
name medication.

Specialty medications are limited to a 30 day supply and must be ordered through Caremark Specialty Pharmacy
at 1-800-237-2767.

Performance Generic Step Therapy: Your employer has implemented performance generic step therapy that promotes the use of
generic medications first before non-preferred brand medications. If you choose to use certain non-preferred brand-name drugs
before trying a generic medication or a preferred brand medication, your prescription may not be covered and you may need to pay
the full cost. Enclosed you’ll find a list of non-preferred brand-name drugs that require you try a generic first. This list can change
quarterly.
DRUGS COVERED*
 Legend Drugs (drugs that require a prescription) Exceptions: See Exclusion list below.
 Acne agents (prior authorization required for age >34)
 ADD/ADHD medications (prior auth required for age >18)
 Narcolepsy medications (prior auth required)  Impotence agents (quantity limits of 6 per 25 days)  Migraine Meds (FDA quantity limits apply)  Compounded medication of which at least one ingredient is a legend drug at a participating pharmacy  Contraceptives: Oral, injectable, diaphragm, transdermal & intravaginal, extended cycle products  Diabetic Care: Insulin/Insulin pre-filled syringes, Agents/Strips, Disposable insulin needles/syringes/lancets  Prescription vitamins  Antifungals (prior authorization required)
 Oral Fentanyl Products (prior authorization required)
 Prescription and OTC smoking cessation (two 12 week programs per calendar year) OTC requires prescription

EXCLUSIONS*
 Biological, blood products, serums and immunization agents  Fertility medications  IUD and Implantable devices for contraception (may be covered under Medical)  Cosmetic agents (Anti-wrinkle agents, Depigmenting agents, Hair growth stimulants and removal products)  Nutritional Supplements  Anti-obesity/Appetite suppression medications  Medication which is to be taken by or administered to an individual, in whole or in part, while he or she is a patient in a licensed hospital, rest home, sanitarium, extended care facility, convalescent hospital, nursing home or similar institution which operates on its premises, or allows to be operated on its premises, a facility for dispensing pharmaceuticals. *This is not an inclusive list but is a representation of the most commonly used medications. Contact customer service for specific drug coverage information. Your employer’s plan is subject to the Affordable Care Act (ACA) which requires the coverage of a number of preventive items and services at 100% and ensures these items and services are not subject to deductibles or other limitations such as annual caps or limits. You can contact Customer Service if you have specific drug questions or register to check drug costs and coverage. For Prescription Drug Card Customer Service Call 1-800-334-8134 NG
Munroe Regional Medical Center October 2012
Brand Medications Requiring Use of a Generic First
You can save money by using safe, effective generic medications when possible. According to your prescription
benefit plan, in order for certain brand-name medications to be covered, you will have to try a generic
medication first. The chart below tells you which kinds of drugs require you to use a generic first. This chart
only provides a sample list of generic drug options and may not include all drugs available.
Drug Class
Step 1: You wil have to try one of
Step 2: Before you can try one of
ACE Inhibitors/Angiotensin II
Receptor Antagonists (ARBs)/
Direct Renin Inhibitors/
Combinations
irbesartan/irbesartan HCTZ lisinopril/lisinopril HCTZ losartan/losartan HCTZ moexipril/moexipril HCTZ quinapril/quinapril HCTZ ramipril trandolapril trandolapril-verapamil ext-rel Antihistamines/Combinations
Bisphosphonates/Combinations
COX-2 Inhibitors/Nonsteroidal
Anti-Inflammatory (NSAIDs)/
Combinations
Fibrates
HMG-CoA Reductase Inhibitors
(HMGs or Statins)/Combinations
Nasal Steroids
For Prescription Drug Card Customer Service Call 1-800-334-8134 NG
Drug Class
Step 1: You wil have to try one of
Step 2: Before you can try one of
Proton Pump Inhibitors (PPIs)
omeprazole-sodium bicarbonate Zegerid Powder for Oral Susp pantoprazole Selective Serotonin Agonists/
Combinations
Selective Serotonin Reuptake
Inhibitors (SSRIs)
Sleeping Agents
Urinary Antispasmodics
*This list indicates the common uses for which the drug is prescribed. Some medicines are prescribed for more than one condition. Brand-name drugs not listed here may be covered by your plan without the use of a generic first. Information provided here is not a substitute for medical advice or treatment. Discuss this information with your doctor or health care provider. CVS Caremark assumes no liability for the information provided or for any diagnosis or treatment made in reliance thereon, nor is it responsible for the reliability of the content. Subject to state law restrictions. This document contains references to brand-name prescription drugs that are trademarks or registered trademarks of pharmaceutical manufacturers that are not af iliated with CVS Caremark. Listed products are for informational purposes only and are not intended to replace the clinical judgment of the prescriber. Targeted therapeutic classes and specific drug targets are subject to change based on new generic drug launches, product approvals, drug withdrawals, and other market changes. 2012 Caremark. All rights reserved. 5295-24684c v1 1012 PGST FE For Prescription Drug Card Customer Service Call 1-800-334-8134 NG

Source: http://www.benefitmovie.com/munroe/documents/Rx%20Summary%20Munroe%20CH-Adv-Net%20CH-Adv%2010-12.pdf