10-PD 1.1 Attachment K- City of RR Plan Design CH+ PS1 Rx Plan Summary.pdf

Client Name: City of Round Rock

Policy: 925175

BPL: K6389 CH+PS1 Plan

Date : 3/9/2026 Program/Benefit Description

Copays

Retail: Tier 1 - $0, Tier 2 -$30, Tier 3 -$50

Mail: 3 x's retail copays Specialty: Same as in-network coverage

3 tier plan

Program/Benefit Description

Accumulators Deductible: N/A

Out of pocket: $5,000 indv/$14,500

FA

Medical and pharmacy combined for out of pocket only

Retail Network Broad

Broad Network: The national network of 67,000+ retail pharmacies that members can use to fill their prescriptions at a discounted rate.

Standard Select Network: This is a medium sized network (50k) with CVS as the selected anchor chain. Improved pricing guarantees due to driving members to one anchor chain.

Value Network: A network that is more narrow than the Broad and Standard networks, at 35,000 retail pharmacies. Includes two of the top three national chains (excludes CVS).

Retail 90/Home Delivery Standard Mail/Home Delivery

Standard Mail/Home Delivery: Indicates that members can fill up to 90 days at OptumRx Home Delivery

CVS90/Mail Service Saver enables members to obtain a 90 day supply of medication at either OptumRx home delivery, or at a CVS Pharmacy location at home delivery pricing. After 2 grace fills* if the member does not fill their prescription via OptumRx home delivery or a CVS Pharmacy, they will be responsible for a higher copayment or cost share.

CVS90/Mail Service Saver Plus enables members to fill a 90 day supply of medication at either OptumRx home delivery or a CVS Pharmacy location for the home delivery pricing. After two grace fills*, if the member does not fill their maintenance prescription at either OptumRx home delivery or a CVS Pharmacy location, the member will be responsible for the full retail cash price of that medication (claim rejects)

Walgreens90/Mail Service Saver enables members to fill medications for 90 days either via OptumRx Home Delivery or at Walgreens. If the member does not move to 90 days via OptumRx Home Delivery or Walgreens, they are responsible for paying a higher copay (at least 50% of the contracted rate). Note:

Program cannot be selected in conjunction with the Value Network.

Walgreens90/Mail Service Saver Plus enables members to fill medications for 90 days either via OptumRx Home Delivery or at Walgreens. If the member does not move to 90 days via OptumRx Home Delivery or Walgreens, the member pays the full cost of the medication (claim rejects).

Program/Benefit Description

Prescription Drug List: Traditional

Prescription Drug List (PDL), also known as a formulary, is a list of medications that are covered by UHC health plans. These medications are organized into different cost levels, called tiers, which can affect how much you pay out-of-pocket for each prescription.

Traditional Generic drugs always in Tier 1; uptiering changes occur only once per year on 1/1. Client can elect exclusions.

Legend Medication with an OTC Equivalent Exclusion:

Yes (Exclude all drugs) Legend Medication with an OTC Equivalent Exclusion The pharmacy benefit standard is to not cover legend medications (requires a prescription) if those products have an OTC (over the counter) equivalent.

Exclude Upon Launch: Yes (Exclude all drugs)

Exclude At Launch UnitedHealthcare works hard to ensure members have timely access to new medications that are supported by appropriate management programs. Newly launched medications may not be covered while UnitedHealthcare evaluates the medications through the Exclude at Launch Program. There are two categories of medications that may be excluded at launch.

l Medications that utilize a new mechanism of action are quickly evaluated to determine if they would benefit from utilization management programs. Once utilization management is approved the medication is covered with appropriate and cost effective coverage.

l Medications that provide marginal value or provide a slight alternation to a medication already available, such as reducing the frequency patients need to take the medication with an added extended-release component or combining two medications to make a new one, are carefully reviewed to determine the most appropriate, cost-effective coverage. This may include tiering, utilization management, and/or permanent exclusion.

Drug / Devices Combination Exclusion:

Yes (Exclude all drugs)

Drug / Devices Combination Exclusion An exclusion program is being implemented for previously approved therapies that are now combined with a device or sensor. A growing category of treatments called digital therapeutics are designed to incorporate devices or sensors with traditional therapies, to track and monitor a patient's medication adherence.

Rx Benefit Summary

PDL Benefits:

Copay Design

Benefit Limits

Authorized Brand Alternative (ABA) Exclusion:

Yes (Exclude all drugs)

Authorized Brand Alternative (ABA) Exclusion Authorized Brand Alternative (ABA) medications occur when manufacturers launch an authorized product identical to the originator product. The Authorized Brand Alternative program is structured to ensure members always have access to the lowest cost product

B4G Generic Exclusions: Yes (Exclude all drugs)

B4G Generic Exclusions In certain situations, the net cost of brand drugs may be less than the cost of generics. The B4G Generic Exclusion program provides a simple mechanism to exclude the higher net cost generic drugs while ensuring selected members can always access the lowest cost product in their deductible phase.

Note: This program may/may not apply to HSA plans

ProactiveRx Program:

Proactive Rx program Once a decision has been made to exclude a drug, some members start therapy on the drug before the exclusion is implemented. The ProactiveRx Program prevents members new to therapy from taking a soon-to-be excluded drug in the 2 months prior to an exclusion being implemented while still allowing members existing on the therapy to access the drug until the standard exclusion date. By encouraging members to begin therapy on a preferred drug it improves the member experience and minimizes situations where a member must switch therapies.

Brand Exclusion when Generic Launches:

No (Cover all drugs)

Brand Exclusion When Generic Launches When a patent expires on a brand drug and a generic enters the market, there could be market conditions that would warrant excluding the Brand and covering the Generic. Enables OptumRx to exclude off-cycle.

PDL Exclusion Program: Yes (Exclude all drugs)

Permanent Exclusions Contains exclusions that all have lower-cost options available. Medications selected for strategic PDL Exclusions must meet certain criteria to be considered for exclusion. For example, UnitedHealthcare Pharmacy may exclude a medication when it is therapeutically equivalent to another covered prescription that either: contains the same active ingredient or contains a modified version of the active ingredient. In addition, UnitedHealthcare Pharmacy may exclude a prescription product if it is therapeutically equivalent to medications available over the counter (OTC). Finding opportunities to control costs for you and your employees is a significant part of UnitedHealthcare Pharmacy’s responsibility as your pharmacy benefit provider. These cost-saving opportunities – along with member experience and satisfaction – are always at the forefront of UnitedHealthcare Pharmacy decision making process.

Program/Benefit Description

Generic Drug Policy (aka Ancillary Charges)

Voluntary - No Ancillary Charges

The Ancillary charge is the cost difference between a generic and its chemically brand medication. The member is required to pay the applicable tier copay plus the difference in cost between the generic and brand name.

- Voluntary - No Ancillary - No additional charge for not using an available generic drug.

- Restricted - Only a physician may request a brand name product if a generic is available. There is no ancillary charge if the physician orders a brand name product, but there is a charge if a member requests it.

- Mandatory - An ancillary charge will apply if generic is available whether a Physician or a Member makes the request.

Generic Drug Policy -Copay

Not Applicable- if Voluntary Policy (Standard Tier applies) If Restricted or Mandatory selected, then the the following Copay design will apply

Designated Specialty Pharmacy Network

Covered

Designated Specialty Pharmacy Network includes specific specialty pharmacies, each chosen based on clinical capabilities, quality of services and cost.

UnitedHealthcare Pharmacy implements disease-specific clinical criteria to identify opportunities for quality improvements, which give the member access to clinical programs that will help manage their therapy through educational resources, adherence support and personalized care. Coverage of specialty medications is based on the customer’s prescription drug list and not dependent on participation in the Specialty Pharmacy Network Program.

Price Edge Yes

Price Edge is a program that ensures members are getting a competitive rate for generic drugs covered by their benefit plan and specific brand and generic drugs not covered by their benefit plan. Price Edge continually compares cash discount card pricing against the member’s expected out of pocket cost share and seamlessly presents the lower price at the point-of-sale. Claims adjudicated on-benefit apply to accumulators and out of pocket maximums; they also have clinical programs and safety checks in place.

Smart Fill Program - Split Fill: Covered

Smart Fill Program / Split Fill Split Fill is directed at members new to therapy with select oral cancer medications and provides the member with two 15 day supply prescriptions per month for the first three months of their treatment, along with additional clinical touchpoints by an Optum Specialty Pharmacy pharmacist. These smaller fills eliminate potential waste and can lower costs when members are not able to continue taking their medication due to adverse side effects.

Program/Benefit Description

Quantity Level Limits:

Covered

Quantity Level Limits (QLL) The QLL program is based on FDA-approved dosing guidelines as defined in the product package insert and the medical literature, guidelines, and data that support the use of other dosages than the FDA-recommended dosage. The program defines the maximum supply of medication per copayment as specified by the plan and limits the amount of medication per copay.

Quantity Per Duration:

Covered

Quantity Per Duration (QPD) The QPD program ensures the member gets the most effective and appropriate therapy possible according to FDA Guidelines and medical literature, or treatment guidelines and defines a maximum amount that can be covered in a one month period. The program limits the amount of medication within a specified period (one month).

1/2 Tab: Covered

1/2 Tab The Half-Tab Program is used when the manufacturer makes available two different strengths of a drug for approximately the same price. The medications involved are in tablet form and are suitable for tablet splitting. The program requires that the member's physician write the prescription for half the quantity of tablets at a double strength dosage, with instructions to take half of a tablet. The consumer receives the prescribed dose and pays half a copayment per prescription (members with a co-insurance plan will save up to 50%). The program is completely voluntary, so members decide whether they participate.

Step Therapy: Covered

Step Therapy The Step Therapy Rx program is a point-of-service program designed to support the pharmacy benefit. Select drugs may require the member to try a more cost-effective drug prior to approval that is consistent with the consumer’s benefit design. Step Therapy Rx programs may require the physician to provide additional information to determine whether the use of certain medications is covered by the pharmacy benefit. Drugs included in the Step Therapy Rx may be based on clinical evidence, economics, or both.

Prior Authorization (MedNec&Notification drugs):

Covered

Prior Authorization (Med Nec & Notification Drugs) Prior Authorization includes the current Notification program plus the Medical Necessity program Medical Necessity: evaluates the clinical appropriateness of a medication in terms of condition being treated, severity of condition, type of medication, frequency of use, and duration of therapy.

Program/Benefit Description

UHC Copay Card Solutions:

Accumulator Adjustment:

Yes

Accumulator Adjustment Accumulator Adjustment program is designed to provide a real-time solution that only includes the amount a member has paid (i.e., does not include amounts that are paid by the pharmaceutical manufacturer’s copay card program) towards a member’s deductible and/or out-of-pocket maximum. The copay card amount and an explanation will be reflected on myuhc.com and on their Explanation of Benefits (EOB).

Benefit Options:

Benefit Limits:

Standard Clinical Programs:

UHC Copay Card Solutions:

Variable Copay

Yes

Variable Copay By leveraging a modified benefit design for a select list of specialty drugs, variable copay optimizes yield from copay coupons already in-use today, reducing client expenditure and maintaining the member experience.

UHC Copay Card Solutions:

Variable Copay - Home Delivery (Non-Specialty)

Yes

Variable Copay Home Delivery (Non-Specialty) By leveraging a modified benefit design for a select list of Non-specialty drugs at home delivery, variable copay optimizes yield from copay coupons already in-use today, reducing client expenditure and maintaining the member experience.

Program/Benefit Description Retail Days Supply 90 days Indicates the maximum days supply for medications in Retail network Home Delivery Days Supply 90 days Indicates the maximum days supply for medications at OptumRx Home Delivery Infertility Not Covered Allows for the option to cover oral, injectable or both medication types with a specified vendor and include additional program elements.

Tobacco Not Covered Allows for the option to cover Tobacco Cessations medications with or without review.

HCR Tobacco Covered with Notification - $0

Member Cost Share Allows for the option to cover Tobacco Cessations medications with or without review or elect the HealthCare Reform program

Growth Hormones Covered Allows for the option to cover Growth Hormone medications at specific member cost share with or without a maximum.

Appetite Suppression/Weight Control Drugs:

Covered - Legend Only with notification

Allows for the coverage of Legend (prescription) or Legend and OTC medications with or without review.

Note: If election is Not Covered - Medical Diagnosis Only , this option allows coverage for other medical conditions.

Oral Contraceptives Covered - 3 cycles for 3 copay Allows for the coverage of oral, vaginal and transdermal contraceptive drugs, medications with a choice of number of cycles per member cost share with or without review or the election for the HealthCare Reform program.

Depo Provera Covered - 3 copays for 90 days Allows for the coverage of injectable Depo-Provera or generic for various member cost share per 90 days or the election of the HealthCare Reform program.

Contraceptive Devices Covered Allows for the coverage of contraceptive devices or the election of the HealthCare Reform program.

Insulin/Insulin Covered The Insulin / Insulin Combination coverage includes all forms, such as, pens, vials, cartridges, and inhalations. Insulin/ GLP-1 combination products, such as Xultophy, Soliqua are included.

Non Insulin and Non Oral Diabetic Medication

Covered Non Insulin and Non Oral Diabetic Medication are medications, such as glucagon-like peptide 1 (GLP-1) injectable products that enhance insulin release (i.e., Mounjaro, Victoza or Trulicity), a non oral hypoglycemic (low blood sugar).

Diabetic Supplies Covered - with Glucometer - no

Insulin Pump Supplies (except Select Products)

The Diabetic Supplies coverage includes a combination of options which include glucometers, test strips, Continuous Glucose Meters (CGM), insulin pump supplies, diabetic needles and syringes.

Oral Diabetic Medications Covered - Base copays apply Oral Diabetic Medication are covered under the pharmacy benefit (except for some limited coverage plans) and don't include Insulins or GLP-1s. This selection that defines copays is new starting in 2023 and had previously been part of the diabetic supply/insulin copays

Erectile and Sexual Dysfunction Covered - Standard

The U.S. Food and Drug Administration (FDA) has approved Cialis to treat Benign Prostatic Hyperplasia (BPH) in addition to Erectile Dysfunction (ED).

Customers who cover Erectile and Sexual Dysfunction will automatically receive Cialis coverage for the treatment of BPH. Notification would also be required to help ensure Cialis is only being covered for BPH. For customers that have step therapy as part of their benefit plan, Cialis will also be subject to step therapy.

Retinoid and Related Products Covered through age 29 then

Notification thereafter Topical products typically used for acne, however, may be used off-label for wrinkles. These are creams, gels or lotions and are standardly single ingredient products containing retinoids or a vitamin A derivative.

Self-Administered Injectables and Supplies

Covered Allows for the coverage of injectable medications and supplies approved by the FDA for member or caregiver can administration for various member cost share. Includes brand name, generic and biosimilar products

Non Self-Administered / Medical Office Setting - PA/MedNec Applies:

No Non Self-Administered Injectables are generally covered under the medical benefit based on FDA approved administration, but may be elected for coverage under the pharmacy benefit.

Non Self-Administered Products / Pharmacy Setting:

Covered An increasing number of states are permitting qualified pharmacists to administer medications that have traditionally limited to a medical office setting. Select medications, once only covered under the medical benefit, may be included under the pharmacy benefit. The UHC standard is to allow coverage of select pharmacist administered products under the pharmacy benefit.

Hemophilia-Factor Products Only: Covered Hemophilia-Factor Products Only program is designed to provide coverage for specific clotting factor products used in the treatment of hemophilia and other bleeding disorders.

Medications for Cosmetic Purposes:

Not Covered Allows for coverage of medications for cosmetic enhancement that are not plan exclusions. Cosmetic medications are standardly not covered.

Durable Medical Equipement Not Covered

Durable Medical Equipment is standardly covered under Medical. These are durable, used for a medical reason, used in the home, and has an expected lifetime duration of at least 3 years.

Examples of DME include: canes, commode chairs, crutches, hospital beds, infusion pumps and supplies, wheelchairs, nebulizers, oxygen equipment and walkers

Devices: Not Covered A medical device is an instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or other similar or related article. Medical devices are intended to affect the structure or any function of the body, and which does not achieve any of its primary intended purposes through chemical action within or on the body and is not dependent upon being metabolized for the achievement of any of its primary intended purposes.

Anabolic Steroids: Covered The standard is to cover a short list of anabolic steroids drugs that are typically used in AIDS wasting and post-surgery/prolonged illness for increasing weight.

Vitamins - Legend: Covered Allows for coverage of Prenatal vitamins, vitamins with fluoride & single-entity vitamins requiring a prescription

Over The Counter Medications: Not Covered Over the Counter Medications are standardly not covered as part of the pharmacy benefit but does not include products such as Insulin or diabetic supplies that can be purchased over the counter.

HCR Preventive Care: Covered

Allows the benefit plan to bypass the deductible and coverage of these medications will be provided without regard to the deductible requirement. As part of Health Care Reform select recommended preventive medications will be covered at 100% when:

- Age and gender-appropriate

- Prescribed by a health care professional (even if they are available OTC)

- Filled at a network pharmacy

Preventive Medications: Not Covered Allows the benefit plan to bypass the deductible for Preventive Medications and define the member cost share for these medications. Categories of medications include but not limited to cardiovascular medications to treat high blood and cholesterol, breast cancer, immunosuppressants, and osteoporosis on the Core program, diabetes, asthma, and depression on the Core Plus / Expanded program and HIV / Multiple Sclerosis on the Expanded program

Drug Coverage Benefits:

Preventive Medications Drug Lists: Not Applicable

Preventive Medication List:

Blank: Not applicable

Core medication list is based on interpretation of the U.S. Department of Treasury clinical guidance including 9 therapeutic classes.

Core Plus medication list includes diabetes and asthma/COPD medications.

Expanded medication list contains all Core medications, plus drugs that have supporting clinical evidence that these drugs help lower costly medical events (hospitalizations/ER visits).

Vital Medication Program: Not Covered The Vital Medication Program is a copay program for preferred insulins and preferred emergency use drugs (e.g., epinephrine, naloxone, glucagon, and albuterol) at a zero-dollar cost share. This program is designed to allow the benefit plan to bypass the deductible and coverage of these medications will be provided without regard to the deductible requirement.

Termination of Pregnancy: Covered This program facilitates coverage of abortifacients in accordance with medical plan documents.

Immunizations/Vaccines:

Covered - Preventive vaccines including Flu & COVID

Coverage for preventive vaccines, which includes the influenza vaccine, is available under the pharmacy benefit. The availability of preventive vaccinations under the pharmacy benefit provides expanded access for our members and aligns with our continued focus on quality of care. This selection does not impact the existing coverage under the medical benefit. This program is designed to allow the benefit plan to bypass the deductible and coverage of these medications will be provided without regard to the deductible requirement

COVID Tests: Not Covered OTC at-home diagnostic COVID tests are used to help diagnose COVID 19 infections.

Diagnostic Kits and Products Not Covered Products/Agents used to help diagnose a condition. Examples include Barium, Drug Assay Test Kits, DNA collection Kits, and Urine collection kits.

Special Instructions:

Program/Benefit Description

Sempre Health Program: Not Covered Offers a member copay incentive when specific medications are filled in a timely manner.

Note: Cannot apply coverage if 90-day Retail and Mail Service Driven Products has "Mail Service Saver Plus"

Advanced Pharmacy Audit Services:

Not Covered A product offering that goes beyond our standard pharmacy audit services to help deliver financial results, strategic insight and increased patient safety, by providing designated auditors, machine-learning technology and client specific reporting.

Polypharmacy Program: Not Covered

Is defined as utilization of five (5) more chronic medications by one person, some of which may be unnecessary or even harmful to the member and may lead to adverse health outcomes and drug interactions. The Program is a collaborative effort between provider, member and pharmacist to perform a comprehensive review of medications.

Other Programs

Cover Legend medication QSYMIA ORAL CAPSULE EXTENDED RELEASE. (Brand and Generic)