Page 9 - 2015 Four Seasons Sante Fe/Vail Enrollment Guide
P. 9
2015 Open Enrollment
Prescription Drug Plan
By enrolling in the medical plan, you receive coverage for your prescription drug medications. To ind which tier
your medication falls under, visit www.mycigna.com or call 1-800-420-1830 for member assistance.
Important Notice for the HSA Plan
Under the HSA Plan, prescription drug expenses are not covered until you have met the medical deductible of
$1,500 individual or $3,000 family.
OAPIN
Prescription Drug Copay Supply (up to the days In-Network HSA 2 Out-of-Network In-Network
listed below)
Generic 30 days $5 after ded 40% coinsurance $5
Preferred Brand 30 days $40 after ded after ded. $30
Non-Preferred Brand 30 days $70 after ded $60
High Cost Self-Injectables 30 days $100 after ded $90
Mail Order 1 90 days 2x Copay N/A 2x Copay
1 The cost is three times the retail copay in Delaware
2 Must meet the deductible before the plan pays at the applicable copay or coinsurance. Once the out-of-pocket maximum is met then
the plan pays at 100%.
Note: Generic and brand name (if a generic is not available or if the brand name is medically necessary) FDA-approved contraceptives
are covered in-network at 100% with no deductible, copay, or coinsurance.
Compound Prescription Drugs Cigna Update
Typically performed by a licensed pharmacist – is the Cigna will require a Prior Authorization (PA) Review
science of combining, mixing or altering ingredients of of Compounded Prescriptions that exceed $200 per
a drug to create a medication tailored to the needs prescription.
of a patient. Today, less than 1% of all prescriptions are Cigna will lower the dollar threshold that triggers PA review
compounded. These mixes are used in instances where a for compound prescriptions from our current threshold of
patient cannot be helped, or may be harmed, by mass- $500, and then to $200 in November 2014. Prescriptions
manufactured drugs. Situations include when a patient is submitted over these price thresholds will be reviewed
unable to swallow in a solid dosage form, or has an allergy for cost and medical necessity. Compounded drugs
or sensitivity to certain ingredients or dyes in a commercial that pass the PA review will continue to be monitored
prescription drug. by Cigna Pharmacy Management. At the same time,
Cigna will watch the practices of some pharmacies
that may attempt to readjust prices. A decision may be
made to remove pharmacies Cigna feels are displaying
improper business practices that can harm the clients and
customers
9
Prescription Drug Plan
By enrolling in the medical plan, you receive coverage for your prescription drug medications. To ind which tier
your medication falls under, visit www.mycigna.com or call 1-800-420-1830 for member assistance.
Important Notice for the HSA Plan
Under the HSA Plan, prescription drug expenses are not covered until you have met the medical deductible of
$1,500 individual or $3,000 family.
OAPIN
Prescription Drug Copay Supply (up to the days In-Network HSA 2 Out-of-Network In-Network
listed below)
Generic 30 days $5 after ded 40% coinsurance $5
Preferred Brand 30 days $40 after ded after ded. $30
Non-Preferred Brand 30 days $70 after ded $60
High Cost Self-Injectables 30 days $100 after ded $90
Mail Order 1 90 days 2x Copay N/A 2x Copay
1 The cost is three times the retail copay in Delaware
2 Must meet the deductible before the plan pays at the applicable copay or coinsurance. Once the out-of-pocket maximum is met then
the plan pays at 100%.
Note: Generic and brand name (if a generic is not available or if the brand name is medically necessary) FDA-approved contraceptives
are covered in-network at 100% with no deductible, copay, or coinsurance.
Compound Prescription Drugs Cigna Update
Typically performed by a licensed pharmacist – is the Cigna will require a Prior Authorization (PA) Review
science of combining, mixing or altering ingredients of of Compounded Prescriptions that exceed $200 per
a drug to create a medication tailored to the needs prescription.
of a patient. Today, less than 1% of all prescriptions are Cigna will lower the dollar threshold that triggers PA review
compounded. These mixes are used in instances where a for compound prescriptions from our current threshold of
patient cannot be helped, or may be harmed, by mass- $500, and then to $200 in November 2014. Prescriptions
manufactured drugs. Situations include when a patient is submitted over these price thresholds will be reviewed
unable to swallow in a solid dosage form, or has an allergy for cost and medical necessity. Compounded drugs
or sensitivity to certain ingredients or dyes in a commercial that pass the PA review will continue to be monitored
prescription drug. by Cigna Pharmacy Management. At the same time,
Cigna will watch the practices of some pharmacies
that may attempt to readjust prices. A decision may be
made to remove pharmacies Cigna feels are displaying
improper business practices that can harm the clients and
customers
9
