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Microsoft word - bebe stores inc - ppo 90 0 plan - caremark.docx
bebe stores, Inc.
EPO 90/0 Plan
Welcome to WellNet!
The information below is a general description of your plan benefits and is not meant to be a complete list or complete
description of available services. Please contact WellNet at 800-442-1101
with specific questions about your program.
PRESCRIPTION DRUG COPAYS
(up to 30 day supply)
(up to 90 day supply)
$150 per member
20% (up to $250)
HOW THE COPAYS WORK
Your plan requires that you meet an Annual Deductible on Brand Drugs only before the plan pays benefits. Once the deductible is met, copays will be charged. Copays are based on the WellNet Select Formulary. A copy of the formulary can be found on www.wellnet.com. * Note - The deductible applies to brand name drugs only.
Generic Substitution Program
Generic copay will be charged to the member plus 100% of the difference in cost between the brand drug and the generic drug when a member or their physician requests the brand name drug be dispensed over its generic equivalent.
Diabetic Drugs and Supplies
All diabetic supplies will be covered at no copay if filled at the same time as injectable insulin or
Quantity Level Limits
The following drugs have quantity limits based on the FDA guidelines for safety:
• Erectile dysfunction drugs – limit is 6 quantity per 25 days/18 quantity per 75 days
• Narcotics • Sleep Aids, such as Ambien and Lunesta – limit is 15 quantity per 31 days
Prior Authorization Program
The drugs listed below require Prior Authorization by your physician
before they will be
dispensed at the pharmacy. Please ensure that your physician has your Rx ID
Ask your doctor to call Prior Authorization
Adderall/XR, Concerta, Desoxyn, Dexedrine, Dextrostat, Focalin, Metadate
before you go to the pharmacy to get your
CD/ER, Provigil, Ritalin/LA, Strattera, Xyrem; Anemia -
Aranesp, Epogen, Procrit; Arthritis -
Arava, Humira, Kineret; Asthma -
Xolair; Cancer -
Gleevec, Iressa, Tarceva, Thalomid; Cox IIs
Celebrex; Erectile Dysfunction
– Cialis, Levitra, Muse,ViagraGaucher Disease -
Amerge, Axert, Frova, Imitrex/NS, Maxalt/MLT, Migranal NS, Relpax,
Zomig/ZMT/NS; Multiple Sclerosis -
Avonex, Betaseron, Copaxone, Novantrone, Rebif;
(Tracleer); Ribavirins -
Copegus, Rebetol, Rebetron, Ribasphere; Select
Infergen, Pegasys, Peg-Intron; Topical Acne -
Atralin, Avita, Retin-A/Micro,
Certain chronic and/or genetic conditions require special pharmacy products, often in the form of
injected or infused medicines. These medications must be filled through Specialty Rx.
Questions? Call WellNet Healthcare at 1-800-
If your medication is injectable in nature and is not an Epi-Pen or Insulin, please contact the
442-1101 so that we may help you coordinate
Specialty pharmacy so they may assist you in coordinating your therapy.
HOW TO GET STARTED WITH MAIL ORDER
The mail service program is designed to save you time and money on your maintenance prescriptions by providing home delivery and allowing you
to purchase a 90-day supply of medication for a discounted price. Choose one of two easy ways to get started: 1)
Ask your doctor to write your prescription for a 3-month supply plus refills. Fill out your mail order form, enclose the prescription(s) and mail it
Use the FastStart
Mail Order program by calling 866-772-9414
. Provide the representative with your name, ID, a list of your medications, your
doctor’s name and number, and a credit card. The representative will call your doctor for you to get the prescription started.
Note: You may wish to call your doctor ahead of time so there is no delay in processing your prescription request.
No matter which method you choose, your first prescription will arrive in approximately 10-14 days.
Once your first prescription is ordered,
register on www.caremark.com to order refills online.
The following drugs/drug classes are covered on this plan:
The following drugs/drug classes are excluded on this plan:
• Federal Legend Drugs (drugs that require a prescription by law)
• Contraceptives – Oral and diaphragms
• Contraceptive injections or devices (i.e., I.U.D., Norplant)
• Over the Counter (OTC) – Allergy and GERD only
• Cosmetic drugs (such as wrinkle agents, hair growth agents)
• Fertility Drugs - $15,000 lifetime max
• Glucose Elevating Agents – Oral/Injectable
• Oral and Self Injectable Specialty drugs through SpecialtyRx
• Over the Counter medication (unless listed as covered)
• Smoking Deterrents – 12 week treatment per lifetime
ELIGIBILITY & CLAIMS
Dependent Student Status
Your plan provides coverage for dependents up to age 26
regardless of student status.
If you have paid out of pocket for a prescription and require reimbursement, please submit your
prescription receipts to WellNet, along with your Member ID and Group Number. WellNet will
submit the claim on your behalf and get you reimbursed (minus the appropriate copay). Please fax
your claims to: Claims Dept. 215-396-1764.
WellNet – Important Phone Numbers & Addresses
Caremark – Important Phone Numbers & Addresses
To check drug cost, find the formulary, speak securely with a registered nurse,
or view your prescription history, please visit www.wellnet.com.
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Case Presentation Optical Coherenc Tomography (OCT) in Susac´s syndrome Marius Ringelstein, MD Resident Neurologist, Dr. med., MD Molecular Neurology Research Group (Head: Prof. O. Aktas), Department of Neurology (Chairman: Prof. H.-P. Hartung), Heinrich-Heine-University, Medical Faculty, Düsseldorf, Germany A 19-year old previously healthy woman presented with disturbance