SMCO-TPA-RFP-APP-B-RxProgram-build.pdf

Client ID: PRXCBE78 Coverage Code: PRXCBE4076

Effective Date: 01/01/2024 Plan Description: Summit County - EPO

Formulary Type: Accord Plan Type: Primary Plan

Coverage For: Retail and Mail Mail Order Vendor: Prime Home Delivery

Day Supply Thresholds by Pharmacy Location

Retail Day Supply: 90 Specialty Retail Day Supply: 30

Mail Day Supply: 90 Specialty Mail Day Supply: 30

HSA Prev Retail Day Supply 90: No

Retail Pharmacy Copayments by Day Supply

Retail Day Supply 1 to 30 31 to 90 Stepped Copays Not Elected

Preferred Generics: $0.00 $30.00

Non Preferred Generics: $0.00 $30.00

Preferred Brands: $20.00 $60.00

Non Preferred Brands: $40.00 $120.00

Mail Pharmacy Copayments by Day Supply

Mail Day Supply 1 to 30 31 to 90 Stepped Copays Not Elected

Preferred Generics: $0.00 $0.00

Non Preferred Generics: $0.00 $0.00

Preferred Brands: $20.00 $40.00

Non Preferred Brands: $40.00 $80.00

Specialty Retail Standard Pharmacy Copayments by Day Supply

Retail Day Supply 1 to 30 Stepped Copays Not Elected Stepped Copays Not Elected

Specialty: 20 %

Max

Specialty: $250.00

Specialty Mail Standard Pharmacy Copayments by Day Supply

Mail Day Supply 1 to 30 Stepped Copays Not Elected Stepped Copays Not Elected

Specialty: 20 %

Max

Specialty: $250.00

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Dispense as Written Penalties

DAW 1 - Prescriber Elects Brand, Member Pays Difference: No

DAW 2 - Member Elects Brand, Member Pays Difference: Yes

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Prescription Benefit Accumulations

Embedded - Each person can meet their individual deductible/OOP max to initiate plan benefits.

(Requires one plan; Both of the Individual and Family fields to populated.)

Non-Embedded - The total family Deductible/OOP max must be paid out of pocket to initiate plan benefits.

(Requires two plans; Only one of the Individual or Family fields to populated.)

Accumulation Details

Accum Method: Calendar Year Retail/Mail Combined: Combined

Embedded/Non Embedded: Embedded

Deductible - Prescription Only

Individual: $ 0.00 Family: $ 0.00

Deductible Rx/Med Combined: No Deductible Included in OOP: N/A

DAW Penalty Applies to Deductible: No

Out of Pocket Maximum - Prescription and Medical Combined

Individual: $ 4,000.00 Family: $ 8,000.00

OOP Rx/Med Combined: Yes DAW Penalty Applies to OOP: No

Lifetime OOP Rx/Med Combined: No

Plan Maximum - Prescription Only

Plan Max Rx/Med Combined: No Plan Max Once Exceeded: N/A

Lifetime Plan Max Rx/Med Combined: No

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Allowed Overrides: recommended one (1) per member per medication every 6 months

Override Damaged: Yes Damaged # of Mbr(s) Per Med: 1 Damaged Every (Months): 6

Override Lost: Yes Lost # of Mbr(s) Per Med: 1 Lost Every (Months): 6

Override Stolen: Yes Stolen # of Mbr(s) Per Med: 1 Stolen Every (Months): 6

Override Vacation Supply: Yes Vacation Supply # of Mbr(s) Per Med: 1 Vacation Supply Every (Months): 6

Limitations

Max Cost Edit Applies: Legacy - Standard Specialty Programs: Exclusive Specialty

Max Cost per Transaction Retail: $1500 Specialty Fills Allowed at Retail: 0

Max Cost per Transaction Mail: N/A Refill Too Soon Retail: 75%

Max Cost - Compounds: Standard Refill Too Soon Mail: 70%

Max Cost per Compound at Retail: $300

High Dollar $15,000 Edit : No

Mail Order Program:

Fills Before Mandatory Mail: Voluntary Apply Mandatory Mail to:

Direct Member Reimbursement - Paper Claims

Direct Member Reimbursement: Yes DMR Code: 99CLN2 - Pay at Contracted Rate

Brand Copay if no Gen.: Brand OON Status: Not Covered

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Diabetic

Insulin: I Lancets: I

Insulin Syringes: I Test Strips & Continuous Glucose Monitors: I

Standard Drug Coverage

Alcohol Deterrents: I Contraceptives: I Sexual Dysfunction: X

Allergy Extracts: I Digital Therapeutics: X Vaccine Network: I

Anabolic Steroids: X Growth Hormone: I Weight Loss Agents: I

Blood/Blood Products: X Infertility: I

Compound Drugs: I Immune Serums: X

Age Limits

Acne Products: 26 Age Limit & Under: I Over Age Limit: I

ADD Drugs: 26 Age Limit & Under: I Over Age Limit: I

Isotretinoin Accutane: 99 Age Limit & Under: I Over Age Limit: I

Drug Coverage Options

High Cost Brands and Generics: Include

Rx with OTC Alternatives

Ulcer Drug, PPI: Yes Ulcer Drug, H2 Antagonists: Yes Non Sedating Antihistamines: Yes

Select Topical Acne: Yes Nasal Steroids: Yes Vision Enhancement: Yes

COVID Test Kits: Yes All Other: Yes

Affordable Care Act Preventive Drug Lists

Grandfather Status: Non-Grandfathered

Aspirin: Yes High Cholesterol: Yes

Bowel Prep: Yes HIV Prep: Yes

Breast Cancer: Yes Iron Supplements: Yes

Contraceptives: Yes Tobacco Cessation: Yes

Fluoride Supplements: Yes Vaccines: Yes

Folic Acid: Yes

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Clinical Program Offerings

Step Therapy: Yes Prior Authorization: Yes

Specialty UM Edits: Yes

Value Max: No Gender Dysphoria Coverage: Yes

Prime Therapeutics Select Savings: Payer Matrix

THIS GROUP HAS ENROLLED IN THE PAYER MATRIX SELECT SAVINGS

PROGRAM – IF ASSISTANCE IS NEEDED THE MEMBER CAN CALL THE

PAYER MATRIX CONTACT CENTER AT 877-305-6202.

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