Copayments and benefits

Prescription drugs

You must preauthorize certain medications, including, but not limited to, long-term maintenance or large-quantity medications, and some provider-administered medications, including high-cost or specialty medications administered in a physician’s office, outpatient facility, or home.

Certain medications require step therapy, which means you must use a preferred alternative medication to treat a condition before moving to another formulary medication.

For some classes of drugs, the benefit is limited by quantity per prescription in accordance with federal, state, and manufacturer guidelines. In addition, certain medications may be subject to age or gender limits.

Expenses do not count toward the plan’s out-of-pocket maximum.

If this is your first time using a medication, purchase a 30-day supply from a retail pharmacy.

If you need more than a 30-day supply, you may save money by purchasing the medication from the mail-order pharmacy.

Medications not covered:

• Drugs not approved by the Federal Drug Administration (FDA)
• Drugs to prevent or delay pregnancy that do not meet current medical criteria
• Dietary or nutritional products, including special diets for medical problems
• Medications used for sexual dysfunction
• Non-formulary medications
• Over-the-counter medications, except as provided for by the terms of the plan
• Products used to stimulate hair growth
• Vitamins, except prescribed prenatal and infant vitamins
• Weight-reduction aids

Medications that are not covered by the plan may be eligible for reimbursement through Flexible Spending.

For more information about the prescription drug benefit, call Navitus at 833-354-2226 or visit memberportal.navitus.com/landing.

We have made every effort to accurately describe the benefits and ensure that information given to you is consistent with other benefit-related communications. However, if there is any discrepancy or conflict between information in this document and other plan materials, the terms outlined in the plan document will govern.

Preventive (All plans)

Contracted or non-contracted pharmacy: The plan pays 100% of DMBA’s allowable amount.