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2014 Custom Rx TBD for Sheet Metal, Air, Rail, and Transportation Workers - LPPO & RPPO
Group Plus Formulary
Effective Date: 01/01/2014 - 12/31/2014
Subject to CMS Approval
30 Day Supplies
30 Day Retail from $0 to
30 Day Retail Cost Sharing Out of Pocket that
Rx Option
Plan/Option
Catastrophic (1)
from Catastrophic to
triggers
Unlimited
Catastrophic
30 Day Mail Order from $0 to
30 Day Mail Order Cost
Out of Pocket that
Rx Option
Plan/Option
Catastrophic
Sharing from Catastrophic
triggers
to Unlimited
Catastrophic
*Tier 1: Generic or Preferred GenericTier 2: Preferred BrandTier 3: Non-Preferred BrandTier 4: Specialty Tier Footnotes
1 Catastrophic: Once a member's True Out Of Pocket (TrOOP) cost reaches $4,550.
Out of Network: Emergency Situations
When a member purchases a drug at an out-of-network pharmacy in an emergency situation:
a. the member will pay the same coinsurance as would have applied at a network pharmacy, but at the out-of-network pharmacy price, and/or,
b. the member will pay the same copayment as would have applied at a network pharmacy, plus the difference between the out-of-network pharmacy price and the network pharmacy price.
2014 Custom Rx TBD for Sheet Metal, Air, Rail, and Transportation Workers - LPPO & RPPO
Group Plus Formulary
Effective Date: 01/01/2014 - 12/31/2014
Subject to CMS Approval
90 Day Supplies
90 Day Retail (2) from $0 to
90 Day Retail Cost Sharing Out of Pocket that
Rx Option
Plan/Option
Catastrophic (1)
from Catastrophic to
triggers
Unlimited
Catastrophic
90 Day Mail Order (2) from $0
90 Day Mail Order Cost
Out of Pocket that
Rx Option
Plan/Option
to Catastrophic
Sharing from Catastrophic
triggers
to Unlimited
Catastrophic
*Tier 1: Generic or Preferred GenericTier 2: Preferred BrandTier 3: Non-Preferred BrandTier 4: Specialty Tier Footnotes
1 Catastrophic: Once a member's True Out Of Pocket (TrOOP) cost reaches $4,550.
2 Retail and Mail Order: Retail and Mail Order benefit for a 90-day supply is limited to Rx formulary Tiers 1-2 and most drugs on Tier 3. Regardless of tier placement, Specialty drugs are limited to a 30-day supply.
Out of Network: Emergency Situations
When a member purchases a drug at an out-of-network pharmacy in an emergency situation:
a. the member will pay the same coinsurance as would have applied at a network pharmacy, but at the out-of-network pharmacy price, and/or,
b. the member will pay the same copayment as would have applied at a network pharmacy, plus the difference between the out-of-network pharmacy price and the network pharmacy price.
General Exclusions
Your benefits do not include the following, except as otherwise noted: Any drug not defined by CMS as a Part D drug; Any drug prescribed for noncovered illness or injury; Any drug you receive before your effective date of coverage, or after the date your coverage has ended; Any costs related to the mailing, sending or delivery of prescription drugs; unless you are utilizing our mail-order pharmacy which includes first class delivery service; More than one prescription for the same drug until at least 75% (up to a 30 day supply) or 83% for anything 31 days or over of the prescription has been used by the member based on the dosage schedule prescribed by the network provider, or if received through the mail-order pharmacy program at least 66% of the previous prescription has been used, exception to this is ophthalmic solutions. The threshold is 70% for ophthalmic solutions obtained at a retail pharmacy (66% remains for mail order); Any fraudulent misuse of this benefit, including prescriptions purchased for consumption by someone other than the member; Any drug determined by us to require prior authorization and prior authorization is not obtained; Prescriptions or refills for drugs that are lost, stolen, spilled, spoiled or damaged; Any refunds or credits for prescription copayments or coinsurance after a prescription has been filled, regardless of whether the request is because of an adverse reaction or a change in the dosage or prescription; Any drug prescribed for intended use other than for indications approved by the FDA; or recognized off-label indications through peer-reviewed medical literature; May exclude drugs such as Viagra, Cialis, Levitra, and Caverject, when used for the treatment of sexual or erectile dysfunction.

Source: http://smart-union.org/files/2013/08/2014-Rx-Proposal-Slick-for-SMART.pdf