Page 8 - 2022 Oerlikon Benefits Guide

Pharmacy Coverage

HDHP / HSA PPO
Pharmacy Provisions In-Network In-Network

Prescription Drug Deductible Combined with medical deductible No deductible
Retail pharmacy (up to a 31-day supply)
Tier 1 90%* $5
Tier 2 90%* $15
Tier 3 90%* $40
Tier 4 90%* $80

Mail Order Pharmacy (90-day supply)
Tier 1 90%* $10
Tier 2 90%* $30
Tier 3 90%* $80

Tier 4 90%* $160
*After deductible
This is a summary of coverage only. For more information, please visit Paylocity.
Be sure to use a pharmacy in the National Pharmacy Network. Out-of-network prescriptions not covered.
All specialty medications must be filled through Alliance Rx Walgreens Prime. However, your local Walgreens pharmacy is not in-
network.

Pharmacy Utilization Management
• Quantity Level Limits: Controls how often or the amount of a prescription you can get filled at once. Quantity
limits help ensure safe and appropriate dosing. They also help reduce waste and overuse.
• Step Therapy: Uses a "step" approach with drugs for certain conditions. This requires members to try preferred
medications as the initial step in treatment before certain non-preferred medications are covered.

• Smart Prior Authorization: At the time of filling the prescription, the system automatically searches the member’s
prescription history for drugs that confirm the covered diagnosis or show that the member tried other treatments.
If the history supports the use of the medication, the pharmacist will be able to fill the prescription immediately. If
not, the pharmacist will see the “Prior Authorization Required” message.
• Soft Mandatory Generic: When you request a brand medication and a generic equivalent is available, you will be
charged the difference in cost between the brand and the generic cost. If your physician requests a brand
medication due to medical necessity, you will not be charged this penalty.

Market Watch Drug Programs
• High Cost, Low Value: Certain prescriptions are not covered, and you can substitute those that provide the same
clinical efficacy at a lower cost.
• New-To-Market Drugs: New medications marketed to directly compete with existing medications are restricted
from coverage until our clinical pharmacists have reviewed them to confirm therapeutic value.
• Over the Counter Equivalents: Certain prescriptions will not be covered when a lower-cost over-the-counter (OTC)
version of the same drug is available.
Copay Armor: Drug manufacturers will assist in paying most or all the member cost share for a high cost medication.
With Copay Armor, only the amount you pay for the prescription will apply toward your plan’s annual out -of-pocket
maximum. This program only applies to the PPO plan and you will need to enroll in the program when PillarRx, the
vendor that Highmark has engaged for this program, reaches out in order to take advantage of the deep discounts.

7