Cm-704-67315-pc1270-00

The Reta Trust
Pharmacy Schedule of Benefits for 2-Tier Formulary
Summary of Benefits
Formulary Brand
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)

** There is a $2000.00 max out of pocket benefit. Once you meet the out of pocket maximum
your copay will be $0**

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.
Present your prescription and Prescription Solutions ID card at any Prescription Solutions Participating Pharmacy. Pay the Copayment for a Prescription Unit or its retail cost, whichever is less.
What do I pay when I fill a prescription?
You will pay only a Copayment when filling a prescription at a Prescription Solutions 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 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).
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). 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), or you can chose to utilize the mail service pharmacy and pay the mail
service copayment ($20 generic, 30% Formulary Brand) for a 90 day supply.

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 Prescription Solutions 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 Prescription Solutions’ 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 www.RxSolutions.com.
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. For more information, please continue to “Medications Covered by Your Benefit” and ADDITIONAL INFORMATION
Medications Covered by Your Benefit
The following medications are included in the Prescription Solutions managed Formulary and are available to your
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 law. 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”).
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. Prescription Solutions 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 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 termination. Drugs or medicines purchased and received prior to the Member’s effective date or subsequent to the Member’s termination. 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 Prescription Solutions’ 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. Prescription Solutions 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 Prescription Solutions. Nothing in this section shall prohibit Prescription Solutions 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 Medications available without a prescription (over-the-counter) or for which there is a nonprescription equivalent available, even if ordered by a Physician. 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. Replacement of lost, stolen or destroyed medications. Prescription Solutions reserves the right to expand the prior authorization requirement for any drug product to assure adherence to FDA-approved indications and national
The Appeals Process
Prescription Solutions 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 Prescription Solutions 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 Prescription Solutions receipt of the appeal. If your case does not meet the criteria for an expedited review, it will be reviewed under the standard appeal process.

Source: http://oakdiocese.org/offices/Ins-Benefits/2-Tier%20SOB%20no%20specialty%20Pacificare%20Members%20with%20percent%20NO%20BC.pdf