Ot9763b.qxd:ot9763b

SISC PRESCRIPTION CO-PAYMENT REFERENCE GUIDE
Express Scripts manages your prescription drug benefit at the request of SISC. Your plan
gives you the option of getting your covered medications through the Medco Pharmacy®
mail-order service, now a part of the Express Scripts family of pharmacies, or at a
participating retail pharmacy.
The chart below provides a summary of your prescription drug benefit co-payments. When you use a participating
When you use the
Type of medication
retail pharmacy, you pay:
Medco Pharmacy mail-order
service, you pay:
$10 co-payment
$25 co-payment
$35 co-payment
$90 co-payment
$200 single/$500 family
$200 single/$500 family
Please note: Any amount of deductible satisfied during the 4th quarter of the year will carry over to the following year. *A generic drug will always be dispensed if one is available. If you purchase a brand-name drugwhen a generic alternative is available, you will pay the generic co-payment plus the difference incost between the brand and the generic, even if your doctor writes “dispense as written” (DAW) onthe prescription. When you visit a participating retail pharmacy and present your member ID card, you will
pay the applicable cost share and receive up to a 30-day supply of the prescribed drug. For
medication you take on an ongoing basis, using the Medco Pharmacy offers you convenience
and potential cost savings. You can get more information about the Medco Pharmacy
mail-order service by calling 1 800 633-2662.
Please visit us online at Express-Scripts.com. After registering, you can access informationabout your benefits, as well as health and wellness resources. You may also contact MemberServices toll-free at 1 800 987-5241. Express Scripts looks forward to meeting all of yourprescription benefit needs. Some drugs may require preauthorization. If the necessary preauthorization is not obtained,the drug may not be covered.
Certain items identified by your plan as preventive care are covered in full and not subject tothe co-pay amounts indicated.
Medications that are not covered by your drug plan
Listed below are medications and medication categories that are not covered under your SISC drug plan. The list may not reflect all non-covered drugs and may be subject to change. To confirm whether a prescription drug you need to take is covered or to check the cost of amedication, visit Express-Scripts.com and click “Price a medication.” (If you’re a first-timevisitor to the site, please take a moment to register. You’ll need your member ID number andthe number from a recent prescription.) You can also get coverage and pricing informationby calling Member Services toll-free at 1 800 987-5241. Please note that this list may not be all-inclusive.
• Anti-wrinkle agents (Renova®, Retin-A®, and Avita® for patients aged 36 and over)• Experimental drugs• Fertility medications (Follistim®, Gonal-f ®, Clomid®, and Repronex®)• Influenza treatments (for example, Relenza® and Tamiflu®)• Medications labeled “Caution—limited by federal law to investigational use”• *Over-the-counter medications (except aspirin, folic acid, fluoride and smoking • Pigmenting/depigmenting agents (hydroquinone, Eldopaque® and Eldoquin®)• Hair growth and hair removal agents (Propecia® and Vaniqa®)• *Vitamins and minerals (except folic acid, fluoride and prescription strengths of prenatal vitamins, hematinics, Rocaltrol® and other oral vitamin D) • Brand non-sedating antihistamines (for example, Clarinex®, Clarinex-D®, Xyzal®) * Coverage is subject to certain plan requirements as may be required by applicable law, includingbut not limited to the Patient Protection and Affordable Care Act. For details on coverage, pleasecontact Express Scripts Member Services at 1 800 987-5241. Members may also visit the websiteand follow the instructions above to price a medication. If there are any coverage requirements, acoverage notes window with details will appear.
(See the reverse side for your plan’s co-payment reference guide.)

Source: http://www.wsd.k12.ca.us/human_resources/benefits/Blue%20Shield%20HMO%20RX%20Coverage.pdf