Health Plan & Formulary Comparison Guide - Claremont Insurance

HEALTH PLAN & FORMULARYCOMPARISON GUIDE

A Simple Resource to Help YouUnderstand Your Benefits

Contents

What Does Prescription Drug Formulary Mean? . . . . . . . . . . . . . 3

How To Use This Comparison Guide . . . . . . . . . . . . . . . . . . . . . . 3

A Note To Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Health Plan Accreditation Status . . . . . . . . . . . . . . . . . . . . . . . . . 4

Prescription Drug Benefits/Copays . . . . . . . . . . . . . . . . . . . . . . . 5-6

Non-Formulary & Mail Order Rx Benefits/Copays . . . . . . . . . . . . 7-8

Brand Name/Generic Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . 9-12

Physician Access & Referral . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13-14

Well Woman & Infertility Benefits . . . . . . . . . . . . . . . . . . . . . . . . 15-16

Prescription Drug Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17-20

Diabetes Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21-22

Important Health Plan Telephone Numbers . . . . . . . . . . . . . . . . . Back Cover

PAGE

2

A Note To MembersPrior to using this Comparison Guide to make a benefit or Healthcare Service Plan decision, please call the

Healthcare Service Plan directly to confirm the accuracy of the information provided . Healthcare Service

Plan phone numbers are listed on the back cover of this booklet . This booklet is a summary only.

The Evidence of Coverage (EOC) and the Certificate of Insurance (COI) contain a complete explanation of

benefits, exclusions, and limitations . The information provided in this brochure is not intended for use

as a benefit summary, nor is it designed to serve as the Evidence of Coverage or Certificate of Insurance.

Please note that you can access your Summary of Benefits and Coverage (SBC), EOC or COI by logging in to

www .calchoice .com/documents/ . If you would like a printed copy of the SBC please contact our Customer

Service Department at 866 .451 .7587 .

What Does Prescription Drug Formulary Mean?A Prescription Drug formulary is an approved list of drugs that have been reviewed for safety, quality, effectiveness

and cost by the physicians and pharmacists on a Healthcare Service Plan’s Rx review panel . A non-formulary

drug refers to a drug that is not included on the approved Rx list for a Healthcare Service Plan . Each Healthcare

Service Plan has its own formulary or approved drug list that is reviewed on a regular basis .

How To Use This Comparison GuideIf you are currently using a brand name drug prescription:

Proceed to the alphabetical listing of brand drugs on pages 9-12 . Next to each brand name drug is its

formulary/non-formulary status in each Healthcare Service Plan . For your convenience, a generic equivalent—

if one is available—is listed directly underneath each brand listing .

If you can’t find your prescription drug in this booklet, or your drug is considered non-formulary:

Visit our online formulary guide at www.calchoiceplus.com or contact your Healthcare Service Plan .

3

NCQA Health Plan Accreditation StatusWhat is NCQA Accreditation?

NCQA stands for the National Committee for Quality Assurance, a not-for-profit organization that evaluates how

well a Healthcare Service Plan manages its clinical and administrative systems in order to improve health care

quality for its members .

An NCQA team of physicians and managed care experts conducts rigorous on and off site evaluations . A national

oversight committee — made up of physicians — analyzes the team’s findings and assigns an Accreditation

level based on the plan’s performance compared to NCQA standards . NCQA has purposely set high standards

to encourage Healthcare Service Plans to enhance their quality . Below are the latest ratings from the NCQA for

health plans participating in CaliforniaChoice 51+ .

The following HMOs have an “Excellent” rating from the NCQA for their commercial products:

Kaiser Foundation Health Plan, Inc . - Southern California (HMO) Kaiser Foundation Health Plan, Inc . - Northern California (HMO)

Western Health Advantage (HMO)

The following HMO has a “Commendable” rating from the NCQA for their commercial products:

Health Net of California, Inc . (HMO)

4

CalChoice® 51+ HMO 15*

CalChoice 51+ HMO 15 Value

CalChoice 51+ HMO 20/$500 Value

CalChoice 51+ HMO 25*


Participating Health Plans

Health Net, Kaiser Permanente, Western Health

AdvantageHealth Net Kaiser Permanente Health Net, Western Health

Advantage Kaiser Permanente

Generic $10 copay $15 copay $10 copay $15 copay $10 copay

Brand $20 copay $150 ded-$30 copay $100 ded-$30 copay $25 copay $25 copay

* The copay shall be the designated amount or the provider’s contract rate, whichever is less .** HSA-Qualified Health Savings Plan

CalChoice® 51+ HMO 25 Value



CalChoice 51+ HMO 40 Value Elect Open Access

Participating Health Plans Health Net Health Net, Western Health

Advantage Kaiser Permanente Health Net Health Net

Generic $20 copay $20 copay $15 copay $20 copay $15 copay

Brand $200 ded-$40 copay $35 copay $30 copay $250 ded-$40 copay $25 copay

Salud HMO y Más HDHP 1500** HSA 1800

Participating Health Plans Health Net Kaiser Permanente Western Health Advantage

Generic $15 copay $0 Per Rx After Ded $0 Per Rx After Ded

Brand $25 copay $0 Per Rx After Ded $0 Per Rx After Ded

Prescription Drug Benefits/Copays

Based on the benefit level you choose, each CaliforniaChoice 51+ HMO offers copay benefits for brand and generic drugs included on each Healthcare Service Plan’s Formulary Listing . Each Healthcare Service Plan maintains a different Formulary Listing of prescription drugs that they will cover . Our Health Plan & Formulary Comparison Guide is provided to assist you in looking up some of the more commonly prescribed drugs . These are the standard HMO prescription benefits for brand and generic drugs (covers a 30 day supply or 100 unit dose):

HMO Rx Benefits:

For HMO Non-Formulary Prescription and Mail Order Benefits/Copays, see page 7

5

CaliforniaChoice 51+ features 4 different Health Net PPO benefit levels, a plan for out-of-state employees and 2 Health Savings Account (HSA) options: CalChoice 51+ HSA 1500 and 2000:

CalChoice® 51+ PPO 250 CalChoice 51+ PPO 500 CalChoice 51+ PPO 1000 CalChoice 51+ PPO 1500

ParticipatingPharmacy

Non-ParticipatingPharmacy*







Generic $10 $10 + 50%* $10 $10 + 50% $10 $10 + 50% $10 $10 + 50%

FormularyBrand $20 $20 + 50%* $20 $20 + 50%* $20 $20 + 50%* $20 $20 + 50%

BrandDeductible N/A N/A $100 $100* $150 $150 $150 $150

CalChoice 51+ HSA 1500 CalChoice 51+ HSA 2000 Flex Net Indemnity(out-of-state)







Generic $10 after plan deductible

$10 + 50%after plan deductible

$15 after plan deductible

$15 + 50%after plan deductible 20% Not Covered

FormularyBrand


$25 + 50%after plan deductible


$30 + 50%after plan deductible 20%* Not Covered

BrandDeductible

All prescription drug benefits are subject to combined medical and prescription drug

deductible of $1500 per individual .







$75 applies to all Rx’s Not Covered

Prescription Drug Benefits/Copays

Based on the benefit level you choose, each CaliforniaChoice 51+ PPO offers copay benefits for brand and generic drugs included on each Healthcare Service Plan’s Formulary Listing . Each Healthcare Service Plan maintains a different Formulary Listing of prescription drugs that they will cover . Our Health Plan & Formulary Comparison Guide is provided to assist you in looking up some of the more commonly prescribed drugs . These are the standard PPO prescription benefits for brand and generic drugs (covers a 30 day supply):

PPO Rx Benefits:

For PPO Non-Formulary Prescription and Mail Order Benefits/Copays, see page 8

6

* Member must try and fill with the generic first . If the member opts for brand without first trying the generic an additional ancillary copay may apply .

An Rx Formulary is an approved list of drugs that have been reviewed for safety, quality, effectiveness and cost by the physicians and pharmacists on a Healthcare Service Plan’s Rx review panel . A non-formulary drug refers to a drug that is not included on the approved Rx list for a Healthcare Service Plan . Each Healthcare Service Plan has its own formulary, or approved drug list, which is reviewed on a regular basis .

Experimental, non-FDA approved, not medically necessary and over-the-counter drugs are not covered under the Non-Formulary benefit of any Healthcare Service Plan . As always, please confirm all information directly with the Healthcare Service Plan prior to making an enrollment decision or accessing coverage .

Non-Formulary & Mail Order Rx Benefits/Copays—HMO

7

Health Net HMO, Elect Open Access & Salud HMO y Más

Kaiser Permanente HMO and HDHP

Western Health Advantage HMO and HSA

HMO 15: Generic $20Brand $40Non-Formulary $100

HMO 15 Value: Generic $30Brand $60Non-Formulary $100$150 Deductible Brand

HMO 25 Generic $30Brand $50Non-Formulary $100 HMO 25 ValueGeneric $40Brand $80Non-Formulary $100$200 Deductible Brand

HMO 40: Generic $40 Brand $70Non-Formulary $100

HMO 40 Value: Generic $40Brand $80Non-Formulary $100$250 Deductible Brand

Elect Open Access: Generic $30Brand $50Non-Formulary $100

Salud HMO y Más: Generic $30Brand $50Non-Formulary $100

Up to 100 Day Supply:

HMO 15: Generic $20Brand $40

HMO 20/$500 Value: Generic $10Brand $30

HMO 25: Generic $20 Brand $50

HMO 40: Generic $30 Brand $60

HDHP 1500: Applies to plan deductible, then $0 copay

No mail order benefit for Non-Formulary

90 Day Supply:



HMO 40: Generic $50 Brand $88Non-Formulary $125

HSA 1800: Applies to plan deductible, then $0 copay

Non-Formulary Benefits—HMOHealth Net HMO, Elect Open Access

and Salud HMO y MásKaiser Permanente

HMO and HDHPWestern Health Advantage

HMO and HSA

$50 Non-Formulary copay applies

Prior authorization may be required .

HMO:If deemed medically necessary by Kaiser Permanente

Physician .

HDHP 1500:If deemed medically necessary by Kaiser Permanente

Physician .

Applies to plan deductible, then $0 copay

HMO:$50 Non-Formulary copay applies .

HSA 1800: Applies to pan deductible, then $0 copay .

Prior authorization may be required .

Mail Order Benefits—HMO

90 Day Supply:

Non-Formulary & Mail Order Rx Benefits/Copays—PPO

* Prescription Drugs are subject to the medical deductible . The submission of a prescription drug claim is required for reimbursement of all outpatient prescription drugs .

8

Non-Formulary Benefits—PPO

Health Net PPO & Indemnity

CalChoice® 51+PPO 250

Participating Pharmacy:

$35

Non-Participating Pharmacy:$35 + 50%

CalChoice 51+PPO 500


$35


($100 per individual Brand deductible

applies)



$35



applies)



$35



applies)

CalChoice 51+HSA 1500


$50 after plandeductible

Non-Participating Pharmacy:

$50 + 50% after plan deductible

CalChoice 51+HSA 2000


$50 after plandeductible

Non-Participating Pharmacy:

$50 + 50% after plan deductible

Flex Net Indemnity(out of state) Participating Pharmacy:

Member has a 20% copay for all

medications regardless of formulary alternatives

Non-Participating Pharmacy:Not Covered


CalChoice 51+

PPO 25090 Day Supply:

Generic $20Brand $40Non-Formulary $70

CalChoice 51+



A separate $100 per individual deductible applies to Formulary and Non-Formulary

Brand drugs

CalChoice 51+




Brand drugs

CalChoice 51+




Brand drugs

CalChoice 51+

HSA 1500*90 Day Supply:


All prescription drug benefits are subject to combined medical and prescription drug deductible of $1500

per individual

CalChoice 51+

HSA 200090 Day Supply:


All prescription drug benefits are subject to combined medical and prescription drug deductible of $2000

per individual

Flex Net IndemnityMembers are allowed

to use the Rx by mail program, however they are not given

any type of discount . Therefore, it is their 20% coinsurance x 3 months

Mail Order Benefits—PPO

Generic equivalentin italics

Brand Name/Generic Coverage

Benefit and copay information on pages 5-8Additional formulary listings for over 600 prescription drugs at www.calchoiceplus.com

This directory of drug formularies was collected from all plans participating in the CaliforniaChoice 51+ Program and is accurate to the best of our knowledge . However, the drug formularies and policies offered through CaliforniaChoice 51+ health plans may change at any time without notice so please keep in mind that this is only a guide and you must verify the information directly with the health plan before making decisions.

9

33 Preferred Preferred over all other drugs in the same therapeutic category.

3 Approved Approved for reimbursement without any restrictions.

PA Prior Authorization Reimbursement will be allowed only when the claim has been submitted to plan officials by a prescriber for review prior to the issuance of a prescription.

NF Non Formulary The Plan lists this drug as not on the formulary. Please see pages 7-8 to review plan’s Benefits/Policies regarding non-formulary drugs.

NR Not Reimbursed The drug is not reimbursed by the plan.

NL Not Listed No information available for this drug. It may or may not be reimbursable. Contact your Healthcare Service Plan for details.

* Restrictions Drug has restrictions. Contact your Healthcare Service Plan for details.

N North

S South

Western Health

Advantage

Kaiser Permanente

HMOHealth Net

HMOHealth Net PPO & HSA

Western Health

Advantage

Kaiser Permanente

HMOHealth Net


AccolateZafirlukast NR* NR* NL* NL

AccuprilQuinapril HCI 33 33 NL* 33

Adalat CCNifedipine 33 33 33 33

AllegraFexofenadine HCI NL NL NL* NL

AltaceRamipril NR* NR* NL* NL

AmbienZolpidem NR* NR* 33 33*

AtivanLorazepam 33 33 33 33

Atrovent Ipratropium Bromide 33 33 33 33

AvitaTretinoin 33 33 33 33*

AxidNizatidine 33 33 NL* NL

Bactrim DSSulfamethoxazole-Trimethoprim 33 33 33 33

Beconase AQNo Generic Available 3* 3* NL* 3

BiaxinClarithromycin 33* 33* 33 33

Cardizem CD Diltiazem HCl Coated Beads 3 3

N - NL*S - 33

NL

Cardura Doxazosin Mesylate 33 33 33 33

Catapres Clonidine HCl 33 33 33 33

Celexa Citalopram Hydrobromide 33 33 33 33

Ciloxan Ciprofloxacin HCl 33 33

N - NL*S - 33 33

Cipro Ciprofloxacin 33 33 33 33

CortisporinNeomycin-Polymyxin-HC 33 33 33 33

Coumadin Warfarin Sodium 33 33 33 33

Cozaar Losartan NR NR 33 33*

Cutivate Fluticasone Propionate 33 33 NL* 33

Daypro Oxaprozin 33 33 NL* 33





10








N North

S South

Western Health

Advantage

Kaiser Permanente

HMOHealth Net


Western Health

Advantage

Kaiser Permanente

HMOHealth Net


Desogen Desogestrel-Ethinyl Estradiol NR NR NL* NL

Diflucan Fluconazole 33* 33* 33 33

Dilacor XR Diltiazem HCl 33 33 33 33

Diovan No Generic Available 3* 3* NL* 3*

Dyazide Triamterene - HCTZ 33 33 33 33

Effexor Venlafaxine HCI 33* 33* 33 33

Estrace Estradiol 33* 33* 33 33

Estraderm Estradiol 33* 33* 33 33

FlexerilCyclobenzaprine HCl 33* 33* 33 33

Fosamax Alendronate NR* NR* N - 33*

S - 3333

Hycodan Hydrocodone-Homatropine 33 33 33 NL

Hyzaar Losartan-Hydrochlorothiazide 33* 33* 33 33*

Imdur Isosorbide Mononitrate 33 33 33 33

Imitrex Sumatriptan NR* NR* 33 33*

Keflex Cephalexin 33 33 33 33

Kenalog in OrabaseTriamcinolone Acetonide 33 33

N - NL*S - 33

33

Lanoxin Digoxin 33 33 33 33

Lasix Furosemide 33 33 33 33

Levaquin Levofloyacin 3* 3* 33 33

Lipitor No Generic Available??? NR* NR* 33 33

Lopressor Metoprolol Tartrate NL NL 33 33

Lorabid No Generic Available NL NL NL* NL

Lotensin Benazepril HCl 33 33 NL* 33

Lotensin HCT Benazepril-Hydrochlorothiazide 33 33 NL* 33

11









N North

S South

Western Health

Advantage

Kaiser Permanente

HMOHealth Net


Western Health

Advantage

Kaiser Permanente

HMOHealth Net


Lotrisone Clotrimazole-Betamethasone 33* 33* NL* 33

Macrobid Nitrofurantoin Monohyd Macro 33 33 33 33

Macrodantin Nitrofurantoin Macrocrystal 33 33 33 33

Micro-K Potassium Chloride 33 33 33 33

Neurontin Gabapentin 33 33 33 33

Nitrostat Nitroglycerin 33* 33* 33 33

Norvasc Amlodipine Besylate 33* 33* 33 33

Plendil Felodipine 33 33 NL* 33

Pravachol Pravastatin Sodium 33* 33* 33 33

Prevacid Lansoprazole NR* NR* NL* 33

Prinivil Lisinopril 33 33 33 33

Prinzide Lisinopril-Hydrochlorothiazide 33 33

N - 33

S - NL* 33

Procardia XL Nifedipine 33 33 33 33

Provera Medroxyprogesterone Acetate 33 33 33 33

Prozac Fluoxetine HCI 33* 33* 33 33

Restoril Temazepam 33* 33* 33 33*

Retin-A Tretinoin 33 33 33 33*

Risperdal No Generic Available NR NR 33 33

Septra DS Sulfamethoxazole-Trimethoprim 33 33 33 33

Soma Carisoprodol 33 33 NL* 33

Tenormin Atenolol 33 33 33 33

Tiazac Diltiazem HCI ER Beads 33 33 NL* NL

Timoptic XE Timolol Maleate 33 33 33 33

TobraDex Tobramycin-Dexamethasone 3* 3*

N - 3S - 33

33











N North

S South

12


Western Health

Advantage

Kaiser Permanente

HMOHealth Net


Western Health

Advantage

Kaiser Permanente

HMOHealth Net


Toprol-XL Metoprolol Succinate 33 33 NL* 33

ValiumDiazepam 33 33 33 33

Vasotec Enalapril Maleate 33 33 NL* 33

Verelan Verapamil HCI 33 33 33 33

Viagra No Generic Available 3* 3* NL* 3*

Xalatan Latanoprost NR* NR* 33 33

Xanax Alprazolam 33 33 33 33

Zantac Ranitidine HCl 33 33 33 33*

Zestoretic Lisinopril-Hydrochlorothiazide 33 33

N - 33

S - NL* 33

Zestril Lisinopril 33 33 33 33

Zithromax Azithromycin 33* 33* 33 33

Zocor Simvastatin 33* 33* 33 33

Zoloft Sertraline HCI 33 33 33 33

Zyloprim Allopurinol 33 33

N - NL*S - 33

33




Q U E S T I O N SHealth Net HMO,

Elect Open Access and Salud HMO y Más

Kaiser PermanenteHMO and HDHP

Western Health AdvantageHMO and HSA

How often can my family members and I change Primary Care Physicians (PCP)?

Once a month Anytime

Once a month - changes are effective at the beginning of the following month, provided the member is not in the course of

treatment or hospitalized and no pending authorizations

Can each family member choose a different Primary Care Physician from different medical groups?

Yes Yes—but only from Health Plan Physicians

Yes—but only from network physicians

Can I refer myself to a specialist?(For OB/GYN referral information, see pages 15-16)

Yes—if using a Rapid Access Provider

OB/GYN: Yes

Other Specialties:Yes—to certain specialties .

Self-refer specialties list varies by geographical region

Yes—to an ophthalmologist only, for your annual eye exam

Does the Health Carrier offer a program to help speed up the specialist referral process?

Yes—some Rapid Access Providers offer express referrals

Yes—referrals come directly from PCP; no other approval is needed

Yes—Advantage Referral Program allows PCP to refer member to

any specialist in the WHA network who participates in the Advantage

Referral Program

Are dependents who live out-of-area covered?

Yes—they may enroll based on the subscriber’s work address (within the

service area) . The dependent must travel to that PPG for non-emergency/non-urgent care services they receive . Services that are covered outside the

HN Service Area are for limited to emergency/urgent services only

Dependent children of Subscriber or Subscriber’s Spouse - Yes .

Other dependents are eligible as long as they do not live in or move

to the service area of another Kaiser Permanente region

Yes—full-time student dependents outside of the service area are covered for emergency

and urgently needed services only

Physician Access & Referral—HMO

CaliforniaChoice 51+ HMO 15, 15 Value, 20/$500 Value, 25, 25 Value, 40, 40 Value and EOA members may go to an Urgent Care Facility contracted through their medical group (PMG) or Individual Practice Association (IPA) for the same copay as their Primary Care Physician (PCP) office visit copay . Please contact your selected PMG or IPA to find out if they contract with an Urgent Care Facility and where it is located, so you will have this information handy when needed .Note: All HMO benefits are covered in-network only .All CaliforniaChoice 51+ Health Plans cover life threatening emergencies anywhere in the world .

13


CalChoice® 51+

PPO 250CalChoice 51+




HSA 1500CalChoice 51+

HSA 2000Flex Net

(out-of-state only)

Anytime – In a PPO, you do not have to

choose a PCP


choose a PCP


choose a PCP


choose a PCP


choose a PCP


choose a PCP

Anytime – In an Indemnity Plan,

you do not have to choose a PCP

Yes - Each family member can make their own physician

choice


choice


choice


choice


choice


choice


choice

Yes – in a PPO, you can choose any

physician


physician


physician


physician


physician


physician

Yes – in an Indemnity Plan, you can choose

any physician

Yes – in a PPO you don’t have to go

through a specialist referral process











Yes – in an Indemnity Plan, you

don’t have to go through a specialist

referral process

Yes Yes Yes Yes Yes Yes Yes

www.calchoiceplus.com

Physician Access & Referral—PPO

All CaliforniaChoice 51+ Health Plans cover life threatening emergencies anywhere in the world .

14



Kaiser PermanenteHMO and HDHP

Western Health AdvantageHMO and HSA

Can a member self-refer to an OB/GYN?

Yes—OB/GYN must be in same medical group* or IPA*

as your PCPAnytime Yes—anytime to an OB/GYN

in the WHA network

How often does health carrier allow a routine PAP smear?

Annually(or as deemed necessary

by physician)

Annually (or as deemed necessary

by plan physician)Annually**

How often does health carrier allow a routine Mammogram?

Annually**As recommended

by Health PlanPhysician

Ages 35 - 39: One during five year period

Ages 40 & over: One every calendar year

Does the carrier cover oral contraceptives?

Plans will cover most female prescription contraceptives at $0

cost share . Coverage on some drugs may not follow the generic and brand

tier system . Please refer to your plan documents1 and Health Net’s

[Recommended Drug List (RDL)], cost share and tier information .

Yes Yes

Well Woman & Infertility Benefits—HMO

* A Medical Group or PMG consists of a group of physicians who are in partnership . The Medical Group makes referrals to specialists and handles its own administration .

** O r as recommended by the U .S . Preventive Services Task Force or the American College of Obstetricians and Gynecologists .

1 Evidence of Coverage (EOC) or Certificate of Insurance (COI) are legal binding documents . If the information in this brochure differs from the information in the EOC or COI, the EOC or COI applies .

An IPA is an Individual Practice Association, made up of a group of physicians who practice in their own separate offices but are part of a central administrator that oversees referrals and other HMO issues . Ask your PCP for the name of the IPA or medical group to which he or she belongs .

15


CalChoice® 51+






HSA 2000Flex Net

(out-of-state only)

In a PPO, you can choose any OB/GYN

anytime


anytime


anytime


anytime


anytime


anytime

In an Indemnity Plan, you can choose any

OB/GYN anytime

Once a year* Once a year* Once a year* Once a year* Once a year* Once a year* Once a year*

Once a year* Once a year* Once a year* Once a year* Once a year* Once a year* Once a year*

Yes Yes Yes Yes Yes Yes Yes

Infertility Treatment: After you are approved for coverage, you can call your health carrier directly to determine what infertility procedures are covered . All cases are reviewed on a case-by-case basis .

* O r as recommended by the U .S . Preventive Services Task Force or the American College of Obstetricians and Gynecologists .

Well Woman & Infertility Benefits—PPO

16

www.calchoiceplus.com


Elect Open Access and Salud HMO y MásKaiser Permanente

HMO

If generic drug is available and doctor has not indicated “dispense as written,” will member receive a generic equivalent rather than the brand name drug?

Yes—or you must pay the brand copay plus the difference

in cost between the brand name & generic equivalent

Yes

If doctor writes “dispense as written” on prescription, is brand name available at the brand copay?

Yes Yes

If doctor writes a prescription and there is no generic available, will member receive brand name drug at generic copay?

No—brand name dispensed at

brand name copay

No—brand name dispensed at brand

name copay

What are my prescription copays for formulary drugs?

Are Non-Formulary drugs covered?$50 Non-Formulary

copay applies

Prior authorization may be required

If deemed medically necessary by Plan Physician

Mail Order

Prescription Drug Benefits—HMO

CalChoice® 51+ HMO 15*:CalChoice 51+ HMO 15 Value:CalChoice 51+ HMO 20/$500 Value: CalChoice 51+ HMO 25*:CalChoice 51+ HMO 25 Value:CalChoice 51+ HMO 40*:CalChoice 51+ HMO 40 Value:Elect Open Access:Salud HMO y Más:

* The copay shall be the designated amount, or 50% of the provider’s contract rate, whichever is less

$10$15

$15$20$20$20$15 $15

Generic $20$30

$25$40$35$40$25$25

Brand

The Brand Rx deductible will apply

90 Day Supply:

All plans: self-injectables are covered in full

* The copay shall be the designated amount, or 50% of the provider’s contract rate, whichever is less

Generic $20$30

$30$40$40$40$30$30

Brand$40$60

$50$80$70$80$50$50

$100$100

$100$100$100$100$100$100

Non-Formulary

17

CalChoice 51+ HMO 15*:CalChoice 51+ HMO 15 Value:CalChoice 51+ HMO 20/$500 Value: CalChoice 51+ HMO 25*:CalChoice 51+ HMO 25 Value:CalChoice 51+ HMO 40*:CalChoice 51+ HMO 40 Value:Elect Open Access:Salud HMO y Más:

No mail order benefit for Non-Formulary

$10

$10$10

$15

Generic $20

$30$25

$30

Brand

Up to a 30 day supply

The Brand Rx deductible will apply

Generic 90 Day Supply:

$20

$10$20

$30

Brand$40

$30$50

$60

Kaiser Permanente HDHP

Western Health Advantage HMO

Western Health Advantage HSA

Yes





Yes Yes Yes


brand name copay


brand name copay


name copay

Covered at $0 copayafter plan deductible

has been met


has been met

Yes–if deemed medically necessary by Plan Physician

HMO - $50 Non-Formulary copay applies


has been met


has been met


has been met

Prescription Drug Benefits—HMO

18

$10

$15

$20

Generic $20

$25

$35

Brand

All plans: self-injectables are covered at 80%

Generic $25

$38

$50

Brand$50

$63

$88

$125

$125

$125

Non-Formulary

Q U E S T I O N S


CalChoice® 51+ PPO 250 CalChoice 51+ PPO 500 CalChoice 51+ PPO 1000

If generic drug is available and doctor has not indicated “dispense as written,” will member receive a generic equivalent rather than the brand name drug?

Yes—or you must pay the brand copay plus the difference between the cost of the brand

name & generic


name & generic


name & generic

If doctor writes “dispense as written” on prescription, is brand name available at the brand copay?

Yes Yes Yes

If doctor writes a prescription and there is no generic available, will member receive brand name drug at generic copay?


name copay


name copay


name copay

What are my prescription copays for formulary drugs?

Participating Pharmacy:Generic: $10Brand: $20

Non-Participating Pharmacy:Generic: $10 + 50%Brand: $20 + 50%



$100 per individual brand deductible applies




Are Non-Formulary drugs covered? Participating Pharmacy:$35


Participating Pharmacy:$35






Mail Order 90 Day Supply: Generic: $20Brand: $40Non-Formulary: $70

90 Day Supply: Generic: $20Brand: $40Non-Formulary: $70





Prescription Drug Benefits—PPO

19


CalChoice® 51+ PPO 1500 CalChoice 51+ HSA 1500 CalChoice 51+ HSA 2000 Flex Net (out-of-state only)


name & generic


name & generic


name & generic


name & generic

Yes Yes Yes The copay is the same as it is for generic medications


name copay


brand name copay


name copay

The copay is the same as it is for generic medications




Participating Pharmacy:Generic: $10 after plan deductibleBrand: $25 after plan deductible

Non-Participating Pharmacy:Generic: $10 + 50% after plan deductibleBrand: $25 + 50% after plan deductible

Participating Pharmacy: Generic: $15 after plan deductibleBrand: $30 after plan deductible

Non-Participating Pharmacy:Generic: $15 + 50% after plan deductibleBrand: $30 + 50% after plan deductible

20% for all medications after Rx deductible




Participating Pharmacy:$50 after plan deductible

Non-Participating Pharmacy:$50 + 50% after plan deductible

Participating Pharmacy:$50 after plan deductible

Non-Participating Pharmacy:$50 + 50% after plan deductible

Yes—non formulary medications are covered, however the

member must first try the generic drug




All prescription drug benefits are subject to combined

medical and prescription drug deductible of $1500 per individual


All prescription drug benefits are subject to combined

medical and prescription drug deductible of $2000 per individual

90 Day Supply with a 20%

coinsurance for each month


Prescription Drug Benefits—PPO

20



Kaiser Permanente

HMO

Kaiser Permanente

HDHP

Western Health Advantage

HMO Western Health Advantage HSA

InsulinCovered under thePrescription Drug

Benefit

Covered under thePrescription Drug

Benefit


Benefit


Benefit


Benefit

Needles/SyringesCovered under thePrescription Drug

Benefit


Benefit


Benefit


Benefit


Benefit

Glucose Monitor

Covered as Medical Supplies,

rather than Prescription Drug Benefit:

CalChoice® 51+ HMO 15—90% CalChoice 51+ HMO 15 Value—85%

CalChoice 51+ HMO 25—80%CalChoice 51+ HMO 25 Value—80%

CalChoice 51+ HMO 40—80%CalChoice 51+ HMO 40 Value—80%

Elect Open Access—80%Salud HMO y Más—80%

Covered as Durable Medical Equipment,


CalChoice 51+ HMO 15—100%

CalChoice 51+ HMO 20/$500 Value—80%

CalChoice 51+ HMO 25—80%CalChoice 51+ HMO 40—50%



Covered at$0 copay, after

Plan deductible hasbeen met



CalChoice 51+ HMO 15—90% CalChoice 51+ HMO 25—70%CalChoice 51+ HMO 40—50%

Up to max $2,500/year



$0 copay, afterPlan deductible has

been met

Chem-Strips and/or Testing Agents

Covered under the Prescription

Drug Benefit

Blood Test Strips are covered as Durable Medical Equipment .

Urine Test Strips are covered under the Prescription Drug

Benefit

Blood Test Strips are covered as Durable Medical Equipment .

Urine Test Strips are covered under the Prescription Drug

Benefit

Covered under the Prescription

Drug Benefit

Covered as Durable Medical Equipment rather than Prescription

Drug Benefit

Insulin Pump


Drug Benefit


Drug Benefit


Drug Benefit


Drug Benefit


Drug Benefit

Insulin Pump Supplies


Drug Benefit


Drug Benefit


Drug Benefit


Drug Benefit


Drug Benefit

Diabetes Benefits—HMO

21


CalChoice® 51+






HSA 2000Flex Net

(out-of-state only)


Benefit


Benefit


Benefit


Benefit


Benefit


Benefit


Benefit


Benefit


Benefit


Benefit


Benefit


Benefit


Benefit


Benefit



In-Network: 90%

Out-of-Network: 70%



In-Network: 80%

Out-of-Network: 60%



In-Network: 80%

Out-of-Network: 60%



In-Network: 80%

Out-of-Network: 60%



In-Network: 80%

Out-of-Network: 60%



In-Network: 80%

Out-of-Network: 50%



80%

Covered under the Prescription Drug

Benefit


Benefit


Benefit


Benefit


Benefit


Benefit


Benefit

Covered as Durable Medical Equipment(Medical Deductible

applies)

In-Network: 90%

Out-of-Network: 70%


applies)

In-Network: 80%

Out-of-Network: 60%


applies)

In-Network: 80%

Out-of-Network: 60%


applies)

In-Network: 80%

Out-of-Network: 60%


applies)

In-Network: 80%

Out-of-Network: 60%


applies)

In-Network: 80%

Out-of-Network: 50%


applies): 80%


applies)

In-Network: 90%

Out-of-Network: 70%


applies)

In-Network: 80%

Out-of-Network: 60%


applies)

In-Network: 80%

Out-of-Network: 60%


applies)

In-Network: 80%

Out-of-Network: 60%


applies)

In-Network: 80%

Out-of-Network: 60%


applies)

In-Network: 80%

Out-of-Network: 50%


applies): 80%

Diabetes Benefits—PPO

22

Health Net 800.361.3366

English/Español, Mon-Fri 8:00 a.m. - 6:00 p.m.

Kaiser Permanente English 800.464.4000

Español 800.788.0616

7 days a week 7:00 a.m. - 7:00 p.m.

Western Health Advantage 888.563.2250

English/Español, Mon-Fri 8:00 a.m. - 5:00 p.m.

PL5008.12.12

866.451.7587www.calchoiceplus.com

Documents

Health Plan & Formulary Comparison Guide - Claremont Insurance