18-Attachment P - PRESCRIPTION BENEFIT COVERAGE 01.01.2026.pdf

Questions?

Contact RxBenefits Member Services for information regarding the prescription drug program at 1.800.334.8134.

Prescription Benefit Coverage City of Amarillo | Administered by RxBenefits, Inc. and Optum, Effective January 01, 2026

Note: Members may contact RxBenefits Member Services at 1.800.334.8134 or visit optumrx.com . If there are any additional questions, please contact your Human Resource Department. Please note the effective date on this documentation is a reflection of the last update to this plan. This document is a current representation of the plan benefit at this time.

City of Amarillo Prescription Plan

Retail Pharmacy Coverage (01-30 Day Supply) In Network Pharmacy

Generic $10.00

Preferred Brand $35.00

Non-Preferred Brand $50.00

Retail Pharmacy Coverage (31-90 Day Supply) In Network Pharmacy

Generic $20.00

Preferred Brand $70.00

Non-Preferred Brand $100.00

Mail Order Extended Supply (01-90 Day Supply) In Network Pharmacy

Generic $20.00

Preferred Brand $70.00

Non-Preferred Brand $100.00

Accumulations

Maximum Out of Pocket Embedded $5,000.00 individual / $10,000.00 family

The calendar year Maximum Out of Pocket applies to pharmacy and medical claims. Each individual family member must meet the individual Maximum Out of Pocket unless the family Maximum Out of Pocket has been met by any two or more covered family members. Once met, your covered prescriptions are paid at 100%. Generic Dispense as Written policy does not apply to the Maximum Out of Pocket.

Specialty Medications Specialty medications are high-cost drugs that are often injected or infused and require special storage and monitoring.

These medications must be obtained through OptumRX specialty pharmacy by calling OptumRX at 1.855.427.4682.

Some exceptions apply. These medications are limited to a 30-day supply. Specialty medications largely fall into the formulary brand category but could also fall into the biosimilar or generic specialty drug category. These medications are subject to the appropriate cost share as listed below. OptumRX Specialty Pharmacy also offers pharmaceutical care management services designed to provide you with assistance throughout your treatment.

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Specialty Medication (01-30 Day Supply) OptumRX

Specialty Generic $65.00

Specialty Preferred Brand $65.00

Specialty Non-Preferred Brand $65.00

Retail and Mail Order Pharmacies City of Amarillo participates in the Optum pharmacy network. Contact RxBenefits Member Services at 1.800.334.8134 to inquire about a specific pharmacy.

Manufacturer Copay Assistance Program (MCAP) Some specialty medications may qualify for third-party copayment assistance programs which could lower your out-of-pocket costs for those products. For any such specialty medication where third party copayment assistance is used, you will not receive credit toward your maximum out of pocket or deductible for any copayment or coinsurance amounts that are applied to a manufacturer coupon or rebate. Your employer has elected to enroll in Optum's CCAA + Variable Copay Solution Specialty Only program.

Generic Policy - Dispense As Written (DAW) If you choose to buy the Brand name drug when a Generic equivalent is available, you will be required to pay the Brand copay/coinsurance plus the difference in cost between the Generic and Brand name drug.

Home Delivery Program

A medication that is used for chronic health conditions on an ongoing or long-term basis (e.g., antihypertensive medication taken daily to control high blood pressure). Your plan allows maintenance medications to be filled in 90-day supplies by mail order pharmacy or at a retail pharmacy location.

Preventive Medications 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, maximum out of pockets, or other limitations such as annual caps or limits. You may contact RxBenefits Member Services at

1.800.334.8134 if you have specific drug questions or register at optumrx.com to check drug costs and coverage.

Compound Drugs For compound drugs to be covered, they must satisfy certain requirements. In addition to being medically necessary and not experimental or investigative, compound drugs must not contain any ingredient on a list of excluded ingredients. Any denial of coverage of a compound drug may be appealed in the same manner as any other drug claim denial under this coverage. Compounded medications equal to or exceeding $300 per script will require prior authorization.

High Dollar Claim Review, Prior Authorization and Appeals program (HDCR)

Medication costs exceeding $1,000 per 30-day supply and $3,000 per 90-day supply require prior authorization.

Low Clinical Value Drug List (LCV)

Separate formulary exclusion list including low clinical value drugs, me too/chemically similar drugs, new to market drugs, and non-essential.

Formulary A list of Food and Drug Administration (FDA) approved Prescription Drugs and supplies developed by a Pharmacy and Therapeutics Committee, and/or customized by Optum or RxBenefits. This list reflects the current clinical judgment of practicing health care practitioners based on a review of current data, medical journals, and research information. In your prescription drug coverage, the Formulary Drug list is used as a guide for determining your costs for each prescription. Drugs not listed on the Premium Formulary may not be covered. Your formulary is Premium Formulary.

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The following lists are not all-inclusive, but rather are lists of the most commonly used prescription drugs. These lists are subject to change. The Optum formulary provides an up-to-date list of medications that may be covered by the program. The Optum formulary may be found online at optumrx.com. You may also contact RxBenefits Member Services at

1.800.334.8134 to learn whether a specific drug is covered.

Covered Drugs and Supplies

The following examples of Covered Drugs and supplies may be available with your prescription benefit coverage. FDA-approved pharmaceuticals requiring a written prescription, issued by a licensed physician, dentist, osteopath, podiatrist, optometrist (licensed professionals) or licensed advance practice certified nurse and dispensed by a licensed pharmacist. Please contact RxBenefits Member Services at 1.800.334.8134 if you have specific drug questions or register at optumrx.com to check coverage.

• ACA Contraceptives (Implantable & intrauterine (IUD) • Diabetic Supplies (Syringes & Needles)

• ACA Contraceptives (oral, extended cycle, injectable, • Erectile Dysfunction transdermal, ring, diaphragms and cervical caps) • Insomnia / Sedatives / Hypnotics

• ACA Non-Contraceptives • Legend Drug Compounds

• ACA Preventative Services List • Legend Vitamins (Rx)

• ADHD/ADD • Migraine Medications

• Abortifacients • Multi-Vitamins

• Allergy Serums (Injectable & Oral) • Narcolepsy

• Androgen • Pain / Narcotics / Opioids

• DEA Schedule V Products • Respiratory Supplies

• Diabetic Medications (Insulin/Non-Insulin) • Smoking Cessation Products

• Diabetic Supplies (Continuous Glucose Monitors) • Specialty Medications

• Diabetic Supplies (Lancets, Lancet Devices, Test Strips, • Standard RX/OTC Equivalents alcohol swabs) • Topical Acne Medications

• Diabetic Supplies (Pumps & Supplies)

Quantity Limits for Covered Drugs

Certain Prescription Drugs are covered up to preset limits. These limits are based upon standard FDA approved dosing for the medications. If you request that a prescription be filled for a drug that is subject to quantity limitations, the prescription will be filled up to the preset limits. In some cases, it may be medically necessary for you to exceed the preset limits. In those instances, Prior Authorization is required. In such cases your doctor may initiate Prior Authorization by calling RxBenefits toll-free at 1.800.334.8134. Many drugs are subject to quantity limitations for patient safety based on FDA guidelines. Your plan has identified the following drug categories for Quantity Limits.

• Anti-Anxiety Medications • Glaucoma Agents

• Anti-Diabetic Agents • Irritable Bowel Syndrome IBS Agents

• Anti-Inflammatory Eye Agents • Migraine Agents

• Anti-Nausea Agents • Nasal Steroids

• Anticoagulants • Non-Opioid Analgesics

• Anticonvulsants • Opioid Analgesics

• Antidepressants • Osteoporosis Agents

• Antipsychotic Agents • Proton Pump Inhibitors

• Asthma and COPD Agents • Sleep Agents

• Contraceptives • Smoking Cessation Agents

• Erectile Dysfunction (ED) Agents • Specialty Medications

For more information about specific drugs subject to coverage limitations, please call RxBenefits Member Services at

1.800.334.8134 or visit optumrx.com.

Prior Authorization and Appeals If a prescription drug claim is wholly or partially denied, you or your authorized representative has the right to appeal the decision. You or your authorized representative may appeal the denial no later than 180 days after receiving notice of an adverse claim decision. Appeals of prescription drug claims are handled by RxBenefits and are decided in accordance with the terms of the plan document. Following a clinical review, one of four actions will occur: the medication is approved, the medication claim is denied, the doctor may decide to withdraw and prescribe a different medication, or the reviewer can dismiss the claim due to lack of communication from the prescriber. Your prior authorizations are handled by RxBenefits.

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If denied, the member may appeal the decision. Upon appeal, a second pharmacist reviewer will evaluate the prior authorization and make a decision (approved/denied). If denied a second time, a final appeal may be made, which is forwarded to an outside medical reviewer. If denied, there are no further appeals.

Your doctor may initiate the Prior Authorization, quantity limit, high dollar claim review or any other rejection process by calling RxBenefits at 1.800.334.8134.

The following medications may require a prior authorization under your plan:

• ADHD Medications • Dry Eye Syndrome Agents

• Acne Oral Medications • GLP-1 (Diabetic Drug)

• Acne Topical Agents • Hypoactive Sexual Desire Disorder (Addyi-HSDD Agents)

• Allergen Extracts • Irritable Bowel Syndrome IBS Agents

• Anti-Infective Agents • Non ADHD Stimulant

• Anti-Obesity/Anorexiants/Appetite Suppressant • Opioid Analgesics

• Anticonvulsants • Specialty Medications

• Asthma and COPD Agents • Testosterone

• Diabetic Agents

• Drug Devices

Discount Program Price Edge (Optum): Your employer is offering a seamless point of sale discount on non-specialty generic drugs and some non-covered products. If available for your medication, this discount will be applied with no action from you, and be captured as part of your benefit.

Exclusions Coverage is not provided for:

• Anabolic Steroids • Homeopathic

• Anti-Obesity/Anorexiants/Appetite Suppressant • Hypoactive Sexual Desire Disorder (HSDD e.i. Addyi)

• Bulk Powder Compounds • Multi-Vitamins with Fluoride

• Diabetic Supplies (Blood Glucose Meters) • Multi-Vitamins with Iron

• Dietary Management • Non-ACA Vaccines

• Electrolyte Replacement • Nutritional Supplements

• Experimental Medications • OTC Naloxone Products

• Fertility Medications (Injectable & Oral) • OTC Outside of ACA Drug List

• Fluoride (Topical with Prescription)

Definitions:

Co-Insurance The percentage of charges a Participant is required to pay for covered prescription drugs.

Copayment (Copay) The specified charge you are required to pay for a Covered Drug.

Brand-Name A Prescription Drug that is protected by a patent, supplied by a single company and marketed under the manufacturer’s brand name.

Generic Drug A generic drug is identical to a brand name drug in dosage form, safety, strength, route of administration, quality, performance characteristics, and intended use. Although a generic drug is chemically identical to its branded counterpart, it is typically sold at substantial discounts from the branded drug’s price.

Over-the-Counter Drug (OTC) Any medical substance that can be purchased without a prescription. OTC medications are not covered by your plan unless otherwise stated.

Non-Preferred Brand Non-Preferred Brand is a Brand Name prescription drug that does not appear on the formulary of Brand Name Drugs designated by Optum as Preferred. Members may pay a higher cost for Non-Preferred Brand-Name Prescription Drugs than for Preferred Brand-Name prescription Drugs.

Preferred Brand Drug Preferred Brand Drug is a prescription drug that appears on the formulary of Brand-Name Prescription Drugs designated by Optum Preferred. This list is subject to periodic review and modifications by Optum. Members may obtain a copy of this list by contacting RxBenefits Member Services at 1.800.334.8134 or by registering on optumrx.com. Members pay a lower copay/co-insurance for Preferred Brand-Name Prescription Drugs than for Non-Preferred Brand-Name Prescription Drugs.

For More Information About the Prescription Benefit Coverage City of Amarillo has partnered with Optum and RxBenefits to provide prescription drug benefits. Optum serves as the pharmacy benefit manager and RxBenefits administers the prescription drug program.

The website, optumrx.com is designed to help you explore ways to track your prescription benefits. You may use the site to locate pharmacies and compare prescription drug costs.

RxBenefits, Inc. does not provide legal advice. Nothing herein or in any other documents provided by RxBenefits, Inc.

should be construed, or relied upon, as legal advice. It is the responsibility of the employer/plan sponsor and not RxBenefits, Inc. to determine the contents of its group health plan document and related summary plan description. The employer/plan sponsor should consult with its legal counsel regarding the contents of its group health plan and summary plan description, and the legal requirements that may be applicable thereto. For plan members with questions about plan coverage, please consult your HR Department.

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