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San Jose Evergreen Community Col ege
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Modified 10/20/30
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Prescription Drug Benefits
efit
This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the s
recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reformlaws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may berequired to make additional changes to this summary of benefits. This proposed benefit summary is subject to the approval of theCalifornia Department of Insurance and the California Department of Managed Health Care.
PLEASE NOTE: This is only a summary of your benefits. Please refer to your Combined Evidence of Coverage and Disclosure
Form (“EOC”)/Certificate of Insurance (“Certificate”) which explains your plan’s Exclusions and Limitations as well as the full
range of your covered services in detail.
At Anthem Blue Cross, we know that prescription drugs are Finding a Participating Pharmacy
the fastest–rising item of your total health care benefits cost. Because our huge pharmacy network includes major drugstore The reasons for the spiraling costs of prescription drugs are chains plus a wide variety of independent pharmacies, it is easy varied and include: a general increase of prescription for you to find a participating pharmacy. You can also find a medication use, an aging population, research and participating pharmacy by cal ing Pharmacy Customer Service at development of new medications and the expense of direct to 800-700-2541 or by going to our Web site at .
consumer advertising. With prescription drug costs increasing An Extensive Network
at twice the rate of medical care, we developed ways to Besides saving you money, our extensive network contain costs so your copays remain affordable, while of pharmacies offers you easy accessibility.
maintaining your access to safe, effective prescription drugs.  In California there are over 5,100 retail pharmacies.
Our Prescription Drug Program provides you with choice, This accounts for nearly 95% of retail pharmacies in flexibility, affordability and access to an extensive network of the state, including al major chains.
 Nationwide there are more than 61,000 chain Getting a Prescription Filled at a Participating Pharmacy
To get a prescription filled, you need only take your prescription Using a Participating Pharmacy
to a participating pharmacy and present your member ID card. The You can substantial y control the cost of your prescription drugs amount you pay for a covered prescription – your copay – wil be by using our extensive network of participating pharmacies.
determined by the drug’s type (whether the drug is a brand-name or Participating pharmacies have agreed to charge you not more than generic medication and whether it is a preferred or non-preferred the prescription drug maximum al owed amount.
medication).
A generic drug contains the same effective ingredients, meets the Using a Non-Participating Pharmacy
same standards of purity as its brand-name counterpart and If you choose to fill your prescription at a non-participating typical y costs less. In many situations, you have a choice of fil ing pharmacy, your costs wil increase. You wil likely need to pay for your prescription with a generic medication or a brand-name the entire amount of the prescription and then submit a prescription drug claim form for reimbursement. If you do not have the originalpharmacy receipt(s) showing the date filled, name and address of Our Preferred Drug Program (PDP) encourages the usage the pharmacy, doctor’s name, NDC number, name of drug and of certain, lower-cost, but equal y effective, prescription medications strength, quantity and days supply, prescription number, and the (preferred drugs) in place of higher-cost medications (non-preferred amount paid, the pharmacist must sign and complete the drugs). The non-preferred list contains medications that require appropriate section of the claim form to ensure proper processing your physician’s approval before they can be substituted for a preferred medication. By al owing this substitution, the PDP helpsyou better manage the increasing cost of prescription drugs whilestill maintaining your access to safe and effective medications.
The fol owing chart summarizes the relation between drug type andyour copay amount at a participating pharmacy: Drug Type
Copay Amount
Anthem Blue Cross /Anthem Blue Cross Life and Health Insurance Company The fol owing chart il ustrates potential increased out-of-pocket authorization are not covered unless you receive a prior approval expenses for going to a non-participating pharmacy: from Anthem Blue Cross.
In order for you to get a drug which requires prior authorization, Out-of-pocket
Out-of-pocket
your physician needs to make a written request to us for you.
costs using a
costs using a
We distribute instructions on how to obtain prior authorization to participating
non-participating
physicians and pharmacies so that you may obtain prior pharmacy
pharmacy
authorization for required medications. You may cal Pharmacy Customer Service, at the tol -free number printed on your member ID card, to receive a prior authorization form and/or list of medications requiring prior authorization.
Supply limits are the proper FDA recommendations for
prescription medication dosage coupled with our determination of specific quantity supply limits to prescription medications. Although our standard pharmacy plans offer a 30-day supply for medications at a retail pharmacy, the supply limit can vary based on the medication, dosage and usage prescribed by your physician.
For example, the supply limit for antibiotics used to treat an infection (e.g., 14 pil s to be taken twice a day for one week) is different than blood pressure medication taken on a routine basis (e.g., 120 pil s to be taken twice a day for 60 days). By adhering to Expense varies
specified supply limits, members are assured of receiving the out-of-pocket
based on the cost
expenses
of the medication
Specialty Pharmacy Program
You may obtain a prescription drug claim form by cal ing Pharmacy Specialty medications are usual y dispensed as an injectable drug, Customer Service at the tol -free number printed on your member but may be available in other forms, such as a pil or inhalant.
ID card or by going to our Web site at .
They are used to treat complex conditions. Prescriptions for a specialty pharmacy drug are covered only when ordered through Home Delivery Prescription Drug Program
the specialty pharmacy program unless you are given an exception If you take a prescription drug on a regular basis, you may want from the specialty drug program (see your EOC/Certificate for to take advantage of our home delivery program. Ordering your medications by mail is convenient, saves time and depending on The specialty pharmacy program wil deliver your medication to you your plan design, may even save you money. Besides enjoying the by mail or common carrier (you cannot pick up your medication).
convenience of home delivery, you wil also receive a greater supply of medications. To fill a prescription through the mail, simply You may have to pay the ful cost of a specialty pharmacy drug complete the Home delivery Prescription form. You may obtain the if it is not obtained from the specialty pharmacy program.
form by cal ing Customer Service, at the tol -free number listed Specialty drugs are limited to a 30-day supply for each fill.
on your ID card or by going to our Web site at .
Programs for Member’s Special Health Needs
Once you complete the form, simply mail it with your copay and We recognize that some of our members have unique health care prescription in the envelope attached to the Home delivery needs requiring special attention. That’s why we developed programs exclusively for them. Our additional medical management programs work in synergy with our pharmacy drug program to help Please note that not al medications are available through members better manage their health care on an ongoing basis.
the Home delivery Program. Specialty pharmacy drugs are not available through the home delivery program, see Specialty Diabetic members can receive free glucometers so that they can
effectively and conveniently monitor their glucose levels.
Out-Of-State Prescription Benefits
Seniors can better monitor their chronic diseases and multiple
Our national network of participating pharmacies is available to medications through our seniors-at-risk program. This program
members when outside California. To find a participating pharmacy, reduces the possibility of toxic drug interactions, and curtails
a member can check our Web site or cal the tol -free number distribution of medications that may adversely affect the senior’s printed on the ID card. When using a non-participating pharmacy outside of California, the member wil fol ow the same procedures Asthmatic members and their families can take advantage of our
for using a non-participating pharmacy in California as program to better control the frequency and severity of the disease.
Members who take multiple prescription medications can take
Additional Features That are Part of your Plan
advantage of our pharmacy utilization management programs that Prior authorization as the term implies, means some drugs
encourage the safe, effective distribution of prescription require prior authorization before you can get them (this is similar to medications. We have a program that protects the welfare of prior authorization for medical services). Prior authorization applies members with multiple prescription medications by careful y to a certain medications that are often a second line of therapy.
monitoring their prescription therapy to help reduce the danger To receive prior authorization, you must meet specific criteria.
The criteria wil be based on medical policy and the pharmacy and For additional information regarding your prescription drug benefits, therapeutics established guidelines. You may need to try a drug please cal Pharmacy Customer Service at the tol -free number other than the one original y prescribed if we determine that it should be clinical y effective for you. Drugs which require prior Covered Services (outpatient prescriptions only)
Per Member Copay for Each Prescription or Refill
Retail Participating Pharmacies
 Generic drugs
 Self-administered injectable drugs, except insulin 20% of prescription drug maximum al owed amount(maximum $150 copay) Home Delivery Program
 Generic drugs
 Self-administered injectable drugs, except insulin 20% of prescription drug maximum allowed amount(maximum $300 copay) Specialty Pharmacy Drugs (may only be obtained
through the specialty pharmacy program)
 Generic drugs
 Self-administered injectable drugs, except insulin 20% of prescription drug maximum allowed amount(maximum $150 copay) Non-participating Pharmacies
Member pays the above retail participating pharmacies copay plus: (compound drugs & specialty pharmacy drugs not covered 50% of the remaining prescription drug maximum at retail participating pharmacies) al owed amount & costs in excess of the prescription drugmaximum al owed amount Supply Limits2
 Retail Pharmacy (participating and non-participating)
30-day supply; 60-day supply for federal y classifiedSchedule II attention deficit disorder drugs that requirea triplicate prescription form, but require a double copay;6 tablets or units/30-day period for impotence and/orsexual dysfunction drugs (available only at retail pharmacies) 1 Preferred Generic Program. If a member requests a brand name drug when a generic drug version exists, the member pays the generic drug copay plus the dif erence in
cost between the prescription drug maximum al owed charge for the generic drug and the brand name drug dispensed, but not more than 50% of our average cost for that type of prescription drug. The Preferred Generic Program does not apply when the physician has specified “dispense as writ en” (DAW) or when it has been determined that the brand name drug is medical y necessary for the member. In such case, the applicable copay for the dispensed drug wil apply.
2 Supply limits for certain drugs may be dif erent. Please refer to the EOC/Certificate for complete information.
The Prescription Drug Benefit covers the following:
 Outpatient prescription drugs and medications which the law restricts to sale by prescription. Formulas prescribed by a physician
for the treatment of phenylketonuria. These formulas are subject to the copay for brand name drugs.
 Insulin.
 Syringes when dispensed for use with insulin and other self-injectable drugs or medications.
 Prescription oral contraceptives; contraceptive diaphragms. Contraceptive diaphragms are limited to one per year and are subject  Injectable drugs which are self-administered by the subcutaneous route (under the skin) by the patient or family member.
Drugs that have Food and Drug Administration (FDA) labeling for self-administration  Al compound prescription drugs that contain at least one covered prescription ingredient.
 Diabetic supplies (i.e., test strips and lancets).
 Prescription drugs for treatment of impotence and/or sexual dysfunction are limited to organic (non-psychological) causes.
 Inhaler spacers and peak flow meters for the treatment of pediatric asthma. These items are subject to the copay for brand  Certain over-the-counter drugs approved by the Pharmacy and Therapeutics Committee to be included in the prescription Prescription drug copays are separate from the medical copays of the medical plan and are not applied toward the Annual
Out-of-Pocket Maximums under the Medical Plan.
Prescription Drug Exclusions & Limitations
Immunizing agents, biological sera, blood, blood products or blood plasma
Drugs used primarily for cosmetic purposes (e.g., Retin-A for wrinkles). However, this wil not Hypodermic syringes &/or needles, except when dispensed for use with insulin & other apply to the use of this type of drug for medical y necessary treatment of a medical condition other Drugs & medications used to induce spontaneous & non-spontaneous abortions Drugs used primarily to treat infertility (including, but not limited to, Clomid, Pergonaland Metrodin), unless medical y necessary for another covered condition.
Drugs & medications dispensed or administered in an outpatient set ing, including outpatienthospital facilities and physicians’ of ices Anorexiants and drugs used for weight loss, except when used to treat morbid obesity(e.g., diet pil s & appetite suppressants) Professional charges in connection with administering, injecting or dispensing drugs Drugs obtained outside the U.S., unless they are furnished in connection with urgent care Drugs & medications that may be obtained without a physician’s writ en prescription, except insulin or niacin for cholesterol lowering and certain over-the-counter drugs approved by the Pharmacyand Therapeutics Commit ee to be included in the prescription drug formulary.
Al ergy desensitization products or al ergy serum Drugs & medications dispensed by or while confined in a hospital, skil ed nursing facility, Infusion drugs, except drugs that are self-administered subcutaneously rest home, sanatorium, convalescent hospital or similar facility Herbal supplements, nutritional and dietary supplements, except for formulas for the treatment Durable medical equipment, devices, appliances & supplies, even if prescribed by a physician, except contraceptive diaphragms, as specified as covered in the EOC/Certificate Prescription drugs with a non-prescription (over-the-counter) chemical and dose equivalent Services or supplies for which the member is not charged except insulin. This does not apply if an over-the-counter equivalent was tried and was inef ective.
Cosmetics & health or beauty aids.
a. There is at least one component in it that is a prescription drug; and
b. It is obtained from a participating pharmacy. Member wil have to pay the ful cost of the
Drugs labeled “Caution, Limited by Federal Law to Investigational Use,” or Non-FDA approved compound medications if member obtains drug at a non-participating pharmacy.
investigational drugs. Any drugs or medications prescribed for experimental indications Specialty pharmacy drugs that must be obtained from the specialty pharmacy program, but, Any expense for a drug or medication incurred in excess of the prescription drug maximum which are obtained from a retail pharmacy are not covered by this plan. Member wil have to pay
the ful cost of the specialty pharmacy drugs obtained from a retail pharmacy that member
Drugs which have not been approved for general use by the State of California Department should have obtained from the specialty pharmacy program.
of Health Services or the Food and Drug Administration. This does not apply to drugs that are Third Party Liability
medical y necessary for a covered condition.
Anthem Blue Cross Life and Health Insurance Company is entitled to reimbursement of benefits Drugs to eliminate or reduce dependency on, or addiction to, tobacco and tobacco products.
paid if the member recovers damages from a legal y liable third party.
This does not apply to medical y necessary drugs that the member can only get with a prescriptionunder state and federal law.
Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and
Anthem Blue Cross Life and Health Insurance Company are independent licensees of the
Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance
Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross
Association.

Source: http://www.sjeccd.edu/hr/benefits/Documents/Anthem%20Blue%20Cross%20Plan%20Rx%20Summary%20for%20Regular%20Employees%20(CURRENT).pdf