State of New Hampshire 2018-203 PBM.pdfThe State of New Hampshire (“State”) provides prescription drug benefits through its Employee and Retiree Health Benefit Plan (HBP) for approximately

State of New Hampshire

REQUEST FOR PROPOSAL

For PHARMACY BENEFIT MANAGEMENT SERVICES

RFP # 2018-203

RESPONSE DUE BY: January 19, 2018 at 2:00 PM Eastern Time (ET)

Department of Administrative Services Risk Management Unit

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Table of Contents

SECTION I: INTRODUCTION ........................................................................................................................ 4 A. Background ................................................................................................................................................ 4 B. Objective .................................................................................................................................................... 4

SECTION II: BIDDING INSTRUCTIONS AND CONDITIONS ................................................................. 7 A. Proposal Conditions for The State of New Hampshire, Department of Administrative Services, Risk

Management Unit ...................................................................................................................................... 7 B. Estimated RFP Timetable ........................................................................................................................ 12 C. Evaluation Process ................................................................................................................................... 12 D. Subcontracting ......................................................................................................................................... 16 E. Vendor Contacts ...................................................................................................................................... 16

SECTION III: REQUIRED PLAN DESIGNS, SERVICES AND PROGRAMS ....................................... 17 Plan Design .............................................................................................................................................. 17 A. General Services ...................................................................................................................................... 17 B. Clinical and Other Programs ................................................................................................................... 20 C. Implementation ........................................................................................................................................ 23 D.

SECTION IV: REQUESTED CONTRACTUAL TERMS ........................................................................... 24

SECTION V: FINANCIAL .............................................................................................................................. 35

SECTION VI: PERFORMANCE GUARANTEES ....................................................................................... 46

SECTION VII: REQUIRED PROTECTION OF CONFIDENTIAL INFORMATION AND DATA SECURITY ........................................................................................................................................................ 52

SECTION VIII: TECHNICAL QUESTIONNAIRE ..................................................................................... 55 ORGANIZATIONAL STABILITY & EXPERIENCE .......................................................................... 55 A. ADMINISTRATIVE, MEMBER & CLAIM PAYING SERVICES ...................................................... 56 B. REPORTING, IT & DATA INTEGRATION ......................................................................................... 59 C. FORMULARY MANAGEMENT & REBATES .................................................................................... 60 D. DRUG UTILIZATION REVIEW ........................................................................................................... 62 E. NETWORK MANAGEMENT & QUALITY ASSESSMENT .............................................................. 64 F. MAIL ORDER ........................................................................................................................................ 65 G. SPECIALTY PHARMACY PROGRAM ............................................................................................... 66 H.

MEDICARE PART D EGWP PROGRAM ............................................................................................ 67 I.

SECTION IX: NETWORK DISRUPTION .................................................................................................... 70

SECTION X: CLIENT REFERENCES ......................................................................................................... 71

APPENDICES: GROUP INFORMATION .................................................................................................... 72

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APPENDIX A ................................................................................................................................................ 73 APPENDIX B ................................................................................................................................................ 74 APPENDIX C ................................................................................................................................................ 75 APPENDIX D ................................................................................................................................................ 76 APPENDIX E ................................................................................................................................................. 77 APPENDIX F ................................................................................................................................................. 78 APPENDIX G ................................................................................................................................................ 83 APPENDIX H ................................................................................................................................................ 91

State of New Hampshire SECTION I

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SECTION I: INTRODUCTION This Request for Proposal (“RFP”) is issued by the Department of Administrative Services, acting through the Risk Management Unit, for a contract for pharmacy benefits manager (PBM) services as described herein. A. BACKGROUND

The State of New Hampshire (“State”) provides prescription drug benefits through its Employee and Retiree Health Benefit Plan (HBP) for approximately 37,100 covered lives. The covered population consists of approximately 24,700 active employees/dependents located throughout the country although primarily in New Hampshire. . Included in the active enrollment is a “Special Group” of approximately 300 subscribers and their dependents from other organizations that have been either legislatively or traditionally offered coverage under the State’s HBP. In addition, the State provides prescription drug benefits to approximately 2,800 non-Medicare retirees/dependents and to 9,600 Medicare retirees1. Retirees are located throughout the country as well.

The chart below outlines the October 2017 enrollment by population and type of plan:

Subscribers Dependents Total Members Active Plan 9,784 14,944 24,728 Non-Medicare Retiree Plan 2,113 684 2,797 Medicare Retiree Plan 9,566 N/A 9,566 Total All Plans 21,463 15,628 37,091

Express Scripts, Inc. has been the State’s PBM since January 1, 2014 and transitioned the Medicare population to an EGWP effective January 1, 2015.

Every two years, the State collectively bargains employee health benefits, including plan design, health promotion programs and employee-facing initiatives, with the State’s unions. There are five unions represented including the New Hampshire State Employees’ Association of New Hampshire, SEIU 1984 (SEA), the New Hampshire Trooper’s Association (NHTA), NHTA – Command Staff, Teamsters Local 633 and the New England Police Benevolent Association (NEPBA) with multiple Locals. At this time, all unions have agreed to the same Active Plan design and programs.

The legislature has exclusive authority to change retiree health benefits for both the Non-Medicare and Medicare State of New Hampshire Retiree Plans. Plan design changes for the Non-Medicare Plan can be implemented mid-year. Plan design changes for the Medicare Plan (EGWP) are subject to CMS requirements for notification of change. Currently, the Non-Medicare and Medicare Plans have similar plan designs.

B. OBJECTIVE 1. The State is seeking proposals to provide PBM services for its Employee and Retiree Health Benefit Plan

(HBP), including the services and programs described in Section III of this document.

As mentioned above, all unions have independently agreed to the same Active Plan design and programs. Due to the existence of collective bargaining agreements (for the Active Plan) and required legislative authorization (for the Retiree Plans), the State requires vendors to duplicate the current Active and Retiree Plans’ copayments, maximum out-of-pockets, retail (31-day) and mail (90-day) supply limits, and mandatory mail order (with opt-out). The State also requires vendors to offer clinical and other programs similar to those outlined within Section III. The State must be notified of any deviations

1 In this RFP document and the supporting information, the “Non-Medicare Retiree Plan” may also be referred to as the “Retiree <65 Plan” and the “Medicare Retiree Plan” may also be referred to as the “Retiree 65+ Plan”.


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from the current clinical and other programs. If no deviations from the current clinical and other programs are identified within your response, the State will assume the prescription drug plan can be duplicated exactly. It is important to note that the State is currently participating in collective bargaining and negotiations with all of the unions. The PBM is expected to implement changes if and when negotiated. The State’s contract with a PBM requires the PBM implement any changes in plan design or coverage to the Active Plan resulting from collective bargaining throughout the term of the contract. In addition, the PBM shall provide financial modeling to assist the State with consideration of plan changes. It is possible for the State to be required to manage multiple plan designs to comply with each of the collectively bargained units. The State reserves the right within any contract awarded under this RFP to re-negotiate elements of the contract as required under collective bargaining agreements. The State’s contract with a PBM requires the PBM to implement any changes in plan design or coverage to the Retiree Plans resulting from legislative authorization throughout the term of the contract. The PBM shall provide financial modeling to assist the State with consideration of plan changes. The State reserves the right within any contract awarded under this RFP to re-negotiate elements of the contract as required by legislative changes.

It is essential that the Vendor “duplicate” plan design, and provide similarity in cost management and clinical programs, services and access to plan members. See Section III and Appendix A for details about plan design, services, and programs for both the Active and Retiree Plans. The following is an excerpt from the 2015 – 2017 collective bargaining agreements pertaining to pharmacy benefits for the Active Plan. The current collective bargaining agreements authorize:

Prescription Drugs – The prescription drug plan shall include the following: 1. Mandatory Mail Order for Maintenance Drugs after three (3) retail purchases per prescription,

with employee opt-out. 2. Mandatory Generic Substitution with DAW 2 (i.e., the only exception is physician ordered

“Dispense as Written”) 3. Co-payments:

a. Retail Co-payments - $10 for each generic medicine/ $25 for each preferred brand name medicine/$40 for each non-preferred brand name medicine.

b. Mail Order Co Payments - $1 for each generic medicine/ $40 for each preferred brand name medicine/$70 for each non-preferred brand name medicine.

4. Exclusive Specialty Pharmacy 5. Traditional Generic Step Therapy 6. Quantity Limits 7. Pharmacy Advisor 8. Maximum out of pocket expenses shall be $750.00 per individual per calendar year and

$1,500.00 per family per calendar year.

Contract Length & Specifics

The State seeks to contract with a qualified Vendor commencing upon approval from the Governor and Executive Council and ending on December 31, 2021 with the option to extend for up to two additional years as mutually agreed and approved by the Governor and Executive Council. The administrative services


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outlined in this RFP shall commence on January 1, 2019. Implementation activities shall commence within seven days of Governor and Executive Council (G&C) approval but in no event earlier than July 1, 2018. Payments for contractual services shall commence January 1, 2019 and shall not be made during the implementation period.

State of New Hampshire SECTION II

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SECTION II: BIDDING INSTRUCTIONS AND CONDITIONS

A. PROPOSAL CONDITIONS FOR THE STATE OF NEW HAMPSHIRE, DEPARTMENT OF ADMINISTRATIVE SERVICES, RISK MANAGEMENT UNIT

1. RFP SCOPE

The Department of Administrative Services, Risk Management Unit, is soliciting proposals for Pharmacy Benefit Management (PBM) Services as described in these procurement documents.

2. MANDATORY INSTRUCTIONS FOR VENDORS

It is required that you complete all sections of the RFP and provide your proposal by the stated proposal submission deadline. Do not alter any parts of this RFP, to include the questions and the question numbering.

Failure to follow these instructions may be grounds for rejection of your RFP response.

3. POINT OF CONTACT

Purchasing Agent, Danielle Bishop, or her designee, shall be the single point of contact for this RFP, whether verbal or written.

4. RFP INQUIRIES

The State will host an Instructions and Conditions conference call on December 14, 2017 at 3pm (Call-in number 1-415-655-0001, access code 738 430 249). The purpose of the call is to answer any procedural questions related to submitting a bid. Questions related to specifications contained herein or the services requested will not be addressed during this call.

All technical questions regarding this RFP, including questions related to the form contract P-37, must be submitted to Danielle Bishop at [email protected]. All questions must be submitted in writing prior to the deadline for Vendor Inquiries and/or Requests for Clarification deadline of December 22, 2017 at 3:00PM ET. The questions will be consolidated and/or paraphrased and responded to via a written addendum, or addenda that will be posted online on or before January 5, 2018.

The Vendor must include complete contact information including the Vendor’s name, telephone number, and e-mail address. The State shall attempt to provide any assistance or additional information of a reasonable nature, which might be required by interested Vendors.

RFP inquiries must be submitted by an individual authorized to commit the organization to provide the services necessary to meet the requirements of this RFP.

Appendix H is a Data Request Form which must be completed and emailed to [email protected] to obtain data referred to in Appendices B and C.

5. ADDENDA

In the event it becomes necessary to add to or revise any part of this RFP prior to the scheduled proposal submittal deadline, the Risk Management Unit shall post any Addenda on the State’s vendor website. Before your submission and periodically prior to the RFP closing, check the website for any addenda or other materials that may have been issued affecting the RFP. The web site address is https://das.nh.gov/Purchasing/vendorresources.asp.

mailto:[email protected]


https://das.nh.gov/Purchasing/vendorresources.asp


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6. VENDOR CERTIFICATIONS

All Vendors must be duly registered as a vendor authorized to conduct business in the State of New Hampshire. Vendors shall comply with the certifications below at the time of submission and through the term of any contract which results from said proposal. Failure to comply shall be grounds for disqualification of proposal and/or the termination of any resultant contract.

• STATE OF NEW HAMPSHIRE VENDOR APPLICATION: Prior to bid award, Vendors must

have a completed Vendor Application Package on file with the NH Bureau of Purchase and Property. See the following website for information on obtaining and filing the required forms (no fee): https://das.nh.gov/Purchasing/vendor.asp

• NEW HAMPSHIRE SECRETARY OF STATE REGISTRATION: A bid award, in the form of a contract(s), will ONLY be awarded to a Vendor who is registered to do business AND in good standing with the State of New Hampshire. Please visit the following website to find out more about the requirements for registration with the NH Secretary of State: http://sos.nh.gov/corp_div.aspx

• CONFIDENTIALITY & CRIMINAL RECORD: If Applicable, by the using agency, the Vendor shall have signed by each of employees or its approved sub-contractor(s), if any, working in the office or externally with the State of New Hampshire records a Confidentiality form and Criminal Record Authorization Form. These forms shall be returned to the individual using agency prior to the start of any work.

7. PUBLIC DISCLOSURE

A. Introduction

Pursuant to RSA 21-G:37, all responses to this RFP shall be considered confidential until the award of a contract. At the time of receipt of proposals, the Agency will post the number of responses received with no further information. No later than five (5) business days prior to submission of a contract to Governor & Executive Council pursuant to this RFP, the Agency will post the name, rank or score of each Vendor.

The State of New Hampshire has made it a priority through the Right-to-Know law (RSA 91-A), the TransparentNH initiative, and other statutes and practices to ensure that government activity is open and transparent. In general, these requirements allow for public review, disclosure and posting of government and public records. As such, the State is obligated to make public the information submitted in response to this RFP, any resulting contract, and information provided during the contractual relationship. The Right-to-Know law obligates the State to conduct an independent analysis of the confidentiality of the information submitted, regardless of whether it is marked confidential.

In addition, the Governor and Executive Council (G&C) contract approval process more specifically requires that pricing be made public and that any contract reaching the G&C agenda for approval be posted online.

B. Disclosure of Information Submitted in Response to RFP

Information submitted in response to this request for proposal (RFP) is subject to public disclosure under the Right-to-Know law after a contract is actually awarded by G&C. Notwithstanding the Right-to-Know law, no information concerning the contracting process, including but not limited to information related to proposals, communications between the parties or contract negotiations, shall be available until a contract is actually awarded by G&C.

Confidential, commercial or financial information may be exempt from public disclosure under RSA 91-A:5, IV. If you believe any information submitted in response to this request for proposal should be kept confidential, you must specifically identify that information where it appears in your submission in

https://das.nh.gov/Purchasing/vendor.asp

http://sos.nh.gov/corp_div.aspx


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a manner that draws attention to the designation. You must also provide a letter to the person listed as the point of contact for this RFP, identifying the specific page number and section of the information you consider to be confidential, commercial or financial and providing your rationale for each designation. Marking or designating an entire proposal, attachment or section as confidential shall neither be accepted nor honored by the State.

Pricing and other information that relates to your contractual obligations in your proposal or any subsequently awarded contract shall be subject to public disclosure regardless of whether it is marked as confidential.

Notwithstanding a Vendor’s designations, the State is obligated by the Right-to-Know law to conduct an independent analysis of the confidentiality of the information submitted in a proposal. If a request is made to the State by any person or entity to view or receive copies of any portion of your proposal, the State shall first assess what information it is obligated to release. It will then notify you that a request has been made, indicate what, if any, information the State has assessed is confidential and will not be released, and specify the planned release date of the remaining portions of the proposal. To halt the release of information by the State, a Vendor must obtain and provide to the State, prior to the date specified in the notice, a court order valid and enforceable in the State of New Hampshire, at its sole expense, enjoining the release of the requested information.

By submitting a proposal, you acknowledge and agree that:

• The State may disclose any and all portions of the proposal or related materials which are not marked as confidential and/or which have not been specifically explained in the letter to the person identified as the point of contact for this RFP;

• The State is not obligated to comply with your designations regarding confidentiality and must conduct an independent analysis to assess the confidentiality of the information submitted in your proposal; and

• The State may, unless otherwise prohibited by court order, release the information on the date specified in the notice described above without any liability to you.

Bidder(s) may submit a redacted copy of their RFP in accordance with this section. This redacted copy shall be subject to review and analysis as referenced above.

C. Electronic Posting of Resulting Contract

RSA 91-A obligates disclosure of contracts resulting from responses to RFPs. As such, the Secretary of State provides to the public any document submitted to G&C for approval, and posts those documents, including the contract, on its website. Further, RSA 9-F:1 requires that contracts stemming from RFPs be posted online. By submitting a proposal you acknowledge and agree that, in accordance with the above mentioned statutes and policies, (and regardless of whether any specific request is made to view any document relating to this RFP), any contract resulting from this RFP will be made accessible to the public online via the State’s website without any redaction whatsoever.

8. TERMS OF SUBMISSION

The State assumes no responsibility for understandings or representations concerning conditions made by its officers or employees prior to and in the event of the execution of a contract, unless such understanding or representations are specifically incorporated into this RFP. Verbal discussions pertaining to modifications or clarifications of this RFP shall not be considered part of this RFP unless confirmed in writing. Any information provided by the Vendor verbally shall not be considered part of that Vendor’s response. By submitting a Proposal, a Vendor agrees that in no event shall the Agency be either responsible for or held liable for any costs incurred by a Vendor in the preparation of or in connection with the Proposal, or for Work performed prior to the Effective Date of a resulting Contract.


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9. SUBMISSION FORMAT

Instructions, formats, and approaches for the development of RFP information contained within the RFP are designed to ensure that the submission of data essential to the understanding of the Vendor’s response is received in a consistent and comparable format.

Your RFP response must be clearly sectioned and tabbed as outlined within this RFP document. (e.g. Section II. Step 1, Step 2, etc.) There is no intent to limit the content of the responses in other than the Vendor’s favor, only to assist the evaluation committee in reviewing each response.

10. PROPOSAL SUBMISSION DEADLINE

All RFP submissions must be received at the Bureau of Purchase and Property no later than 2:00 PM ET on Friday, January 19, 2018. Submissions received after the date and time specified will be marked as late and will not be considered. All offers shall remain valid from the proposal submission deadline until the contract award. A Vendor’s disclosure or distribution of proposals other than to the Department of Administrative Services, Bureau of Purchase and Property, shall be grounds for disqualification. No more than one (1) proposal per respondent shall be submitted. Vendors shall submit their proposal to:

State of New Hampshire C/O Danielle Bishop, Administrative Services New Hampshire Bureau of Purchase and Property 25 Capitol Street Concord, NH 03301-6312 (603) 271-3290

Proposal responses shall be marked as: State of New Hampshire, RFP # 2018-203 Due Date: January 19, 2018 @ 2:00 PM ET

Administration of Medical Benefits

11. RFP DELIVERY

Your RFP response must conform to the following criteria in order to be considered for evaluation:

a. RFP submissions shall be hard copies.

b. RFP responses shall be addressed as described in Item 10 above

c. Exterior of the package shall be permanently marked identifying the submitting party’s name and address.

d. Package shall be sealed (tape, glue etc.).

e. RFP submissions may be hand delivered, mailed, or sent via package delivery service (UPS, FedEx, courier). In all cases, the Bureau of Purchase and Property must receive your submission no later than the due date and time.

f. Vendors are encouraged to confirm delivery of their submissions by calling 603-271-2201 or by emailing [email protected].

g. RFP responses must include:

i. One (1) original (clearly identified as such) of your RFP responses to Sections II to X, including Appendix C (Enrollment and Top 100 Brand workbook file), Appendix D (Plan Deviations Form), and any Addenda in numerical sequence and signed;

ii. Eight (8) conforming copies (clearly identified as a copy) of your RFP responses;



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iii. One (1) redacted copy of your RFP response, including a letter identifying confidential information, as referenced in 7.b. above; and

iv. Two (2) electronic* copies of your RFP responses on secure thumb drives. a) The two (2) electronic copies of your RFP shall include responses to all questions in

Sections II to X of this RFP document in MS Word format. DO NOT PDF your response.

b) The two (2) electronic copies of your RFP shall also include the Appendix C “Enrollment and Top 100 Brand” workbook file in MS Excel format. DO NOT PDF your response.

v. The original RFP response must include Appendix E, State of NH Transmittal Letter, signed by a person authorized to bind the company to all commitments made in the RFP response. Failure to submit the Transmittal Letter with your response will result in rejection of your response.

vi. RFP responses transmitted by facsimile or e-mail shall not be accepted or reviewed.

* In the event of a discrepancy between a proposal response received in paper and electronic copy, the paper copy identified as the ‘original’ shall prevail. The State shall not be held liable for any costs incurred by the Vendor in preparing or submitting an RFP response. Any and all damage, which may occur due to shipping, is the Vendor’s responsibility.

12. ADDITIONAL INFORMATION

The State reserves the right to:

• Make a request for additional information in writing from a Vendor to assist in understanding or clarifying a proposal response;

• Waive minor or immaterial deviations from the RFP requirements, if determined to be in the best interest of the State;

• Omit any planned evaluation step if, in the Agency’s view, the step is not needed; • Reject any and all proposals, or any part thereof.

13. RIGHT TO CONSIDER AVAILABLE INFORMATION

The State reserves the right to consider available information regarding the Vendor, whether gained from the Vendor’s proposal, question and answer conferences, references, or any other source during the evaluation process. This may include, but is not limited to, information from the New Hampshire Department of Insurance, as well as any other state or federal regulatory entity.

14. RESTRICTION OF CONTACT WITH STATE EMPLOYEES

From the release date of this RFP, all contact with personnel employed by or under contract with the State related to this RFP, except the point of contact specifically mentioned in this Section II, Item 3 of this RFP, is prohibited. Improper contact is grounds for rejection of your response.

15. CANCELLATION

The State reserves the right to cancel all or any part of this RFP at any time. Cancellation of this RFP, in whole or in part, shall not bar the State from issuing an RFP for the same services or from purchasing the same services through other means.

16. ETHICAL REQUIREMENTS

From the time this RFP is published until a contract is awarded, no Vendor shall offer or give, directly or indirectly, any gift, expense reimbursement, or honorarium, as defined by RSA 15-B, to any elected official, public official, public employee, constitutional official, or family member of any such official


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or employee who will or has selected, evaluated, or awarded an RFP, or similar submission. Any Vendor that violates RSA 21-G:38 shall be subject to prosecution for an offense under RSA 640:2. Any Vendor who has been convicted of an offense based on conduct in violation of this section, which has not been annulled, or who is subject to a pending criminal charge for such an offense, shall be disqualified from bidding on the RFP, or similar request for submission and every such Vendor shall be disqualified from bidding on any RFP or similar request for submission issued by any state agency.

17. REQUIRED CONTRACT TERMS AND CONDITIONS

a. The form contract P-37 (attached hereto as Appendix F) shall form the basis for any resulting contract. The successful Vendor and the State, following notification of award, shall promptly execute the P-37 contract, as amended by the parties to incorporate the service requirements of this RFP, price conditions established by the Vendor’s offer, and any other reasonable administrative practices and services.

b. The form contract Business Associate Agreement (attached hereto as Appendix G), is required to

comply with the Health Insurance Portability and Accountability Act, Public Law 104-191 and with the Standards for Privacy and Security of Individually Identifiable Health Information, 45 CFR Parts 160 and 164 and those parts of the HITECH Act applicable to business associates, shall be promptly executed by the successful Vendor and State, following notification of contract award.

B. ESTIMATED RFP TIMETABLE

Action Due Date (Eastern Time)

RFP Released December 8, 2017

Vendor Conference Call for Procedural Questions

December 14, 2017 3:00 PM ET Call-In Number: 1-415-655-0001 Access Code: 738 430 249

Deadline for Vendor Inquiries and/or Requests for Clarification and Proposed Specification Changes

December 22, 2017 at 3:00 PM ET

Response to Vendor Inquiries and/or Requests for Clarification and Proposed Specification Changes

No later than January 5, 2018

Proposal Submission Deadline January 19, 2018 at 2:00 PM ET

Contract Effective Date Wednesday, July 1, 2018 or Upon Governor & Executive Council (G&C) approval

Contract Implementation Period G&C Approval through December 31, 2018

TPA Effective Date January 1, 2019

C. EVALUATION PROCESS

Segal Consulting has been retained by the State to assist in the evaluation of each Vendor’s responses for completeness and responsiveness to the RFP and to assist in the review of such responses. The State’s designated evaluation team will review and score Vendor responses and select the highest-ranking proposal. All proposals will be evaluated in accordance with the State procedures set forth in Steps #1 through #4 below.


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STEP #1: MINIMUM QUALIFICATIONS

Each proposal shall be evaluated initially to determine compliance with the State of New Hampshire’s Minimum Qualifications. Any proposal that fails to meet one (1) or more of the following eight (8) qualifications shall be eliminated from further consideration for this contract. Any proposal that meets all of the minimum qualifications shall be further evaluated in accordance with the State’s selection criteria. Therefore, to receive further consideration, a proposal must check “YES” to each of the following questions and comply fully with the “Submission Requirement(s)” for each such qualification. 1. Is the Vendor able and willing to demonstrate its financial stability?

[ ] YES [ ] NO Submission Requirements: a) Vendor’s most recent financial report; b) most recent independent auditor’s report; and c) SSAE 16, SAS-70, or equivalent external audit of Vendor’s operations. Attach to proposal.

2. Has the Vendor provided as part of its proposal the contractual terms and fee and cost information

requested in Sections IV and V?

[ ] YES [ ] NO Submission Requirements: Full and complete responses to the Section IV (Requested Contractual Terms) and Section V (Financial) of this RFP.

3. Has the Vendor responded to the performance guarantees set forth in the Performance Guarantees Section VI of the RFP and placed at least $400,000 at-risk annually?

[ ] YES [ ] NO

Submission Requirement: Provide an annual at-risk amount of at least $400,000 and provide a complete response to the Performance Guarantees Section VI.

4. Has the Vendor provided as part of its proposal all information requested in this RFP including all

information requested in the Technical Questionnaire Section VIII?

[ ] YES [ ] NO Submission Requirements: Full and complete responses to all of the information requests made in Section VIII of this RFP.

5. Has the vendor a sufficient retail network that minimizes disruption for the State’s membership? Vendor must meet the following retail network match: 95% or greater of the retail scripts dispensed to the State’s members during November 1, 2016 through October 31, 2017, must have been from pharmacies currently in vendor’s retail network.

[ ] YES [ ] NO Submission Requirement(s): A full and complete response to Section IX – Network Disruption will allow the State to confirm this minimum qualification.


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6. Has the Vendor provided as part of its proposal complete client reference information requested in the Client References Section X?

[ ] YES [ ] NO Submission Requirements: Full and complete responses to all of the information requested in Section X.

7. Does the vendor have experience working with a minimum of five (5) states, large municipalities, or other governmental entities similar to the State?

[ ] YES [ ] NO Submission Requirement(s): Demonstrate such experience by providing the total number of public entity clients with at least 25,000 members.

8. Does the vendor have experience servicing a client with at least 37,000 members with plans and

services similar to those currently offered by the State?

[ ] YES [ ] NO Submission Requirement(s): Demonstrate such experience by providing the total number of clients with at least 37,000 members. If a bid includes a separate contractor (partner, subsidiary, etc.) for EGWP services, the separate contractor must also demonstrate its experience by providing its total number of clients with at least 9,000 members.

STEP #2: FINANCIAL SCORING (60 TOTAL POINTS)

The financial proposals (Section V) will be scored based on the total projected costs (TPC) (i.e., claims and administrative costs) as determined by the State for the three-year period from January 1, 2019 to December 31, 2021. The lowest cost proposal will receive 100% of the 60 points allocated for the Financial Score. All other financial proposals will be scored on a sliding scale where the vendor’s score will be reduced by 2 points for every percentage point it is higher than the lowest cost proposal. As the scale is sliding, scores will be adjusted for partial percentage differences.

The following exhibit illustrates how the financial score will be calculated from the 60 points available:

Formula

Example, where: Lowest Bid TPC = $1,000 and Vendor TPC = $1,025

A Cost Difference = (Vendor’s TPC / Lowest Bid TPC) – 1 ($1,025 / $1,000) – 1 = 0.025

B Convert Decimal to Percent Value = A x 100 0.025 x 100 = 2.5

C 2 Point Reduction per Percentage Higher = 2 x B 2 x 2.5 = 5.0

Vendor’s TPC Score = 60 - C 60 – 5.0 = 55.0


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STEP #3: NON-FINANCIAL SCORING (40 TOTAL POINTS)

The Vendor’s response to information requested in Sections IV, VI, and VIII of the RFP will be evaluated based on the extent to which the Vendor documents conformance with specifications, as well as the completeness, soundness, and creativity of the Vendor’s response, all as evaluated by the State.

The State will evaluate proposals based on technical criteria, including:

• Requested Contractual Terms Score – the extent to which the Vendor demonstrates a willingness to agree to the requested terms. (15 Points; Section IV)

• Performance Guarantees Score – the extent to which the Vendor demonstrates a willingness to agree to the requested performance guarantees and the proposed dollar amount at risk. (5 Points; Section VI)

• Technical Questionnaire Score – the extent to which the Vendor demonstrates its

o experience and ability to provide the requested services and reporting (5 points; Section VIII.A,B,C)

o ability to manage its formulary and retail and mail network pharmacies, and to provide drug utilization review (5 points; Section VIII.D,E,F,G)

o commitment to manage the specialty drug program and its costs (5 points; Section VIII.H)

o its ability to administer the Medicare Part D EGWP program (5 points; Section VIII.I)

STEP #4: CONTRACT AWARD

The State shall award a contract, if at all, to the Vendor submitting the highest ranked proposal. Formal and final selection of the Vendor, however, is contingent upon the successful negotiation and the proper execution of all contract documents (acceptable to the State) and the approval of the Governor and Executive Council. If the State is unable to reach agreement with the Vendor, the State may, at its sole discretion and at any time and without liability to the Vendor, immediately terminate such contract discussions with the Vendor and undertake discussion with the Vendor submitting the next highest ranked proposal, and so on.

Evaluation of the proposals shall include the criteria below. Vendors will receive scores up to the maximum points allocated to each item outlined below.

Criteria Points Section(s) FINANCIAL* 60 V REQUESTED CONTRACTUAL TERMS 15 IV PERFORMANCE GUARANTEES 5 VI TECHNICAL QUESTIONNAIRE 20

Organizational Stability & Experience Administrative, Member, & Claim Paying Services Reporting, IT, & Data Integration

5 VIII.A, VIII.B and VIII.C

Formulary Management & Rebates Drug Utilization Review Network Management & Quality Assessment Mail Order

5 VIII.D, VIII.E, VIII.F, and VIII.G,

Specialty Pharmacy Program 5 VIII.H Medicare Part D – EGWP Program 5 VIII.I

TOTAL POINTS 100

* All fees to be assumed by the State for all the requested services shall be included in the financial section of this RFP.


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D. SUBCONTRACTING

Subcontracting of services shall require prior approval by the State. If your organization plans to utilize subcontractors for any portion of the services identified in this RFP, please include the subcontractor information, to include an outline of the services or functions in which you would plan to subcontract, the length of your relationship with the subcontractor, and a brief company profile.

Vendor shall be accountable for the performance of all subcontractors and shall be responsible for all performance guarantee penalties (See Section VI) that may result from underperformance of the subcontractor.

E. VENDOR CONTACTS Designate the individual(s) with the following responsibilities: The individual(s) representing your company during the RFP process: Representative Name:______________________ Phone #:______________ Email: ___________________ The individual(s) responsible for day-to-day service (if different):

Representative Name:______________________ Phone #:______________ Email: ___________________

State of New Hampshire SECTION III

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SECTION III: REQUIRED PLAN DESIGNS, SERVICES AND PROGRAMS

PLAN DESIGN A.

Due to the existence of collective bargaining agreements and required legislative authorization, the State requires Vendors to duplicate the active and retiree plan designs.

Please review the attached Summaries of Benefits in Appendix A and complete the “Plan Deviations Form” located in Appendix D. If no deviations are provided on this form, it will be assumed that your organization can administer the current plan designs exactly as written in the following attached Summary of Benefits.

Commercial Plans

• SONH Rx - Active Summary.pdf

• SONH Rx – Non-Medicare Retiree Summary.pdf

• SONH Rx - Mandatory Mail Order - Opt Out.pdf

Medicare Plan • SONH Rx – EGWP BenefitOverview.pdf

Please see Section C below for requested clinical and cost management programs.

GENERAL SERVICES B.

To be eligible to receive a score for the Technical Questionnaire in Section VIII, Vendors are required to offer comprehensive PBM services with a full range of customer (client and member) service including, but not limited to:

Indicate the name and address of the legal entity providing any of the services below, if different than the bidding entity.

• Claims Adjudication • Member Enrollment and Eligibility Maintenance • Integration of PBM services with the State’s other vendors/programs (e.g., medical, wellness) • Patient and Provider Education • Systematic Prospective, Concurrent and Retroactive Drug Utilization Review • Network Pharmacy Management • Mail Service Pharmacy (Mandatory Mail after 3 refills, with opt-out) • Exclusive Specialty Pharmacy Program • Clinical and Cost Management Programs (including, but not limited to Traditional Generic Step

Therapy, Drug Quantity Limits, and Mandatory Generic Substitution with DAW2) • Formulary Management and Rebate Sharing • Data Sharing* and Reporting (standard and ad-hoc reporting) • Distribution of ID Cards • Access to Pharmacy Directories • Member Services (including website, portal, and mobile app) • Online systems for the State, and its designee(s) • EGWP Administration / Subsidy Support Services

* NOTE: For the purpose of this analysis, “Data Sharing” is referenced in relation to requests for data and reports from either party (the State or the selected PBM). The State currently shares data between the PBM and medical administrator, University System of New Hampshire and may, over the course


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of the contract term, add other vendors, including, but not limited to a data-warehousing vendor if retained by the State.

The requirements set forth below shall be minimum service requirements to be provided by the successful Vendor:

1. The State requires that the Vendor administer run-out claims for 12 months following termination of the contract. The cost of run-out administration must be included in your proposed administration fees.

2. The State requires that Vendor agree to accept payment of claims and administrative expense invoices via Electronic Funds Transfer.

3. The State requires a minimum of 23 group breakouts for purposes of reporting. In addition, a lesser number of COBRA breakouts will be required.

4. The State requires that the Vendor work with the State’s eligibility systems. The State utilizes the Global Human Resources and Human Resources Management modules of the Infor/Lawson ERP (enterprise resource planning) software for human resources, benefits and payroll functions to manage the State Plan’s eligibility.

5. The State requires that the Vendor’s system(s) shall be able to give credit for charges applied to out-of-pocket maximums that accumulated with a prior carrier.

6. The State requires that the Vendor provide the State quarterly reports detailing plan performance and address account and member service issues, federal and state PBM and pharmacy legislation and legislative trends and development in the market. The State requires that the Vendor attend a mid-year and annual plan performance review for each plan year in person. Additionally, the State requires an annual performance or “stewardship” meeting within 90 days after contract year-end at which time the Contractor will, as directed by the State, summarize activities and performance for the year ended.

7. The State requires the assignment of a dedicated Account Executive and Clinical Account Executive. Both shall be accountable to the State for proactive management of all aspects of the Vendor’s performance to the State and its members. The Account Executive and Clinical Account Executive shall remain constant, within the Contractor’s control, for at least the first 18 months of the contact period. The Vendor shall not change assignment of the Account Executive and Clinical Account Executive without written notice provided to the State with a minimum of fourteen (14) days prior to such change. The State reserves the right to request assignment of a new Account Executive and/or Clinical Account Executive and the Vendor shall make such change within 30 days of receipt of written notice from the State.

8. The State requires the Vendor to attend annual open enrollment meetings as needed. Currently the State requests that the PBM attend only one annual enrollment meeting. The Vendor shall attend other meetings as required by the State.

9. The State expects the Vendor to have the ability to produce ID cards and/or temporary proof of benefit letters in “real time”.

10. The State requires that the Vendor provide a designated customer service toll-free phone number to be answered by a live person in the United States. The State requires 24/7 customer services hours.


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11. The State requires that the Vendor provide automated services, which are available 24/7.

12. The State requires the Vendor provide members access to EOB statements at no cost to the State.

13. The State requires that the Vendor have the ability to have an independent audit performed of your claim operation at no cost to the State.

14. The State requires that Vendors guarantee adherence to New Hampshire RSA 420-J:8-a regarding prompt pay. The law mandates timeframes for all claims [15 days electronic, 30 days paper claims, overdue (interest payment required if timeframes are not met), denied and pended (inform providers within 15 days (electronic claims) or 30 days (paper claims) and adjudicate with 45 days of receipt of additional].

15. The State requires you provide dedicated staff in the following specialties: a. Implementation Manager b. Account Executive c. Pharmacist Account Executive d. Account Manager e. Financial Analyst f. Customer Service Manager


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CLINICAL AND OTHER PROGRAMS C.

The State requires that the Vendor administer the following programs. Any additional fees associated with these programs must be provided in your response to the Financial Section of this document. The Vendor is also required to outline EGWP clinical utilization management programs separately from the commercial programs.

Confirm that you are proposing to administer the State’s clinical and other programs as outlined in the following charts. Please specify if any additional fees apply in your response below and in your response to the Financial Section of this document.

DIRECTED GENERIC VENDOR RESPONSE

When a generic equivalent is available but the pharmacy dispenses the brand-name medication for any reason other than a doctor’s “dispense as written” or equivalent instructions, the member pays the generic copayment plus the difference in cost between the brand-name and generic.

CLINICAL PROGRAMS VENDOR RESPONSE

1. Prior Authorization See prior authorization lists included in files provided in Appendix A

• Active Plan “SONH Rx - Active Summary.pdf” “SONH Rx - Active Booklet.pdf”

• Non-Medicare Retiree Plan “SONH Rx – Non-Medicare Retiree Summary.pdf” “SONH Rx – Non-Medicare Retiree Booklet.pdf”

2. Traditional Generic Step Therapy • Applies edits to drugs in specific therapeutic classes at

the point of sale. • Coverage for back-up therapies (second/third step) is

determined at the patient level based on the presence or absence of front-line drugs or other automated factors in the patient’s claims history.

• Systems support automatic concurrent review of patients’ claims profile for use of front-line alternatives

• Only claims for patients whose histories do not show use of first-step products are rejected for payment at the point of sale.


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CLINICAL PROGRAMS VENDOR RESPONSE

3. Drug Quantity Management/Limits Program • Manages prescription costs by ensuring that the quantity

of units supplied for each copayment are consistent with clinical dosing guidelines.

• Designed to support safe, effective, and economic use of drugs while giving patients access to quality care.

• Clinicians maintain a list of quantity limit drugs, which is based upon manufacturer-recommended guidelines and medical literature.

• Online edits help make sure optimal quantities of medication are dispensed per copayment and per days’ supply.

4. Cholesterol Program • Targets PCSK9 inhibitors • Prior authorization • Specialist pharmacist support and patient engagement • Total cost guarantee

5. Diabetes Program • Total cost guarantee • Preferred pharmacy network for 90-day supply • Resources and support center

6. Hepatitis Program • Specialized through exclusive specialty pharmacy • Prior Authorization

7. Compound Management Solution

8. Morphine Milligram Equivalent Dosing

9. Provide other clinical utilization management programs that you offer that could assist the State with managing drug trend.

DRUG UTILIZATION REVIEW (DUR) PROGRAMS VENDOR RESPONSE

1. Alerts to physicians and pharmacists:

• Severe drug interactions

• Drug interaction


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DRUG UTILIZATION REVIEW (DUR) PROGRAMS VENDOR RESPONSE

• Drug allergy

• Drug disease

• Therapy duplication

• Excessive daily dosing

• Excessive duration of therapy

• Sub-therapeutic dosing

• General contraindications

• Refill-too-soon

• Refill-too-late

• Potential drug name confusion

2. Alerts for special populations

• Seniors (Excessive daily dosing, Drug age contraindications, Drug disease, Drug interactions)

• Pediatrics (Drug age contraindications, Excessive daily dosing)

• Women’s health (Drug pregnancy, Oral contraceptives, Fertility agents)

• Cancer patients (Lethal course of chemotherapy)

THERAPEUTIC INTERVENTION PROGRAM VENDOR RESPONSE

• Intervention when prescriptions written for non-formulary products pass program-specific screening criteria. The prescriber is contacted (via phone or fax) and PBM submits a request to use the Drug List product. If the prescriber agrees to use the Drug List alternate, it is dispensed to the plan participant replacing the original, non-formulary product. A letter explaining that the plan participant's physician was contacted will accompany the Drug List medication when shipped. Additional "value-added" materials, offering educational information on the Drug List product, are sent to the plan participant.

• PBM provides physicians with a toll-free number that will connect them directly to a registered pharmacist who is available to answer any questions regarding PBM's Drug List.


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IMPLEMENTATION D.

Implementation activities shall commence after Governor and Executive Council (G&C) approval but in no event earlier than July 1, 2018.

The Vendor shall provide a preliminary implementation plan and timeline for commercial and EGWP in its bid and identify its implementation team members, as well as the State resources required for the implementation. The timeline shall include a pre-implementation readiness audit to be performed by the State’s designee (See Section V for the requested allowance.) No later than one week after Governor & Executive Council approval, the Vendor shall submit a more detailed implementation plan and timeline for the commercial and EGWP plans to meet the State’s needs and subject to the State’s approval that will include but not be limited to the following:

• Key implementation team member(s), including their contact information. Must include a dedicated EGWP implementation lead.

• Development of eligibility and enrollment interface between Vendor and State system, including all special campaigns per the collective bargaining agreements

• Import and testing of existing enrollment data from State and current Medical TPA, as needed • Successful test of claims adjudication • Receive at least 12 months of claims history, including open refill file for mail claims and current plan

overrides • Testing of Rx data transfer from the State’s current PBM • Development of process for ongoing data transfer between the State’s claims data management system

(when determined and in place) and the Vendor • Establish process for data and reporting access by the State • Development of a Comprehensive Communication plan with defined targeted audiences to include but

not be limited to DAS, employees, retirees, state agencies, providers and other plan participants • Support of the State’s October/November 2018 Open Enrollment for 2019 Plan Year • Include examples of proposed employee communications newsletters, posters, etc. • Delivery of prescription drug benefit program information and ID cards to plan participants prior to

1/1/2019 • Access to the Vendor’s online client and member portals as directed by the State

The project plan shall be updated thereafter as the State and Vendor mutually agree. Implementation activities shall be conducted in close collaboration and with the approval of the DAS.

State of New Hampshire SECTION IV

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SECTION IV: REQUESTED CONTRACTUAL TERMS

The State requests the following contractual terms. You are required to respond to each contractual term and indicate your organization’s willingness to comply by having an authorized representative of your organization provide his/her initials next to each contractual term. Electronic initials shall be accepted. Any requests for changes to the Requested Contractual Terms shall be part of this proposal and the basis for contract discussions. Your response to this Section is mandatory. Any requested contractual term left unanswered shall be considered a no response.

IMPORTANT NOTE: The items identified with a “+” are preferred by the State. If a vendor does not agree to provide the preferred contractual terms, it will be adversely reflected in their score. These are item numbers: 6,12b-f, 13a-k, 14, 26, 28, 30, 31, 33, 38, 39, 40, 44, and 54.

GENERAL TERMS YES NO

1. PBM agrees to a three-year contract term (plus implementation months)

that may be renewed for up to two additional years upon terms and conditions as the parties may mutually agree and upon the approval of the Governor and Executive Council.

2. PBM agrees to a mid-contract term market check, that may start as soon as the second quarter of the second contract year, conducted by an independent third party (of the State’s choosing) to ensure the State is receiving appropriate current pricing terms competitive with the industry (as compared to other PBMs) based on its volume and membership, and will improve pricing in the event that the State’s contract terms are less than current. The State will have the right to terminate without penalty if the pricing terms are not industry competitive.

3. PBM agrees to implement new pricing within 90 days of completion of the market check or signature of contract. Acceptance of the new pricing will apply for the remainder of the Initial Term and will NOT result in extension of the contract, unless requested by the State. The financial guarantees for any partial contractual year that results from the implementation of new pricing will still be guaranteed, reconciled and the PBM will still make payments for any shortfalls for those partial contractual years with less than 12 months and those contractual years with over 12 months.

4. PBM contract will provide 120-days advance notice of renewal rates,

which shall then be subject to negotiation and written agreement between the parties.

5. PBM agrees to provide a signature ready (meaning non-executed) contract incorporating all agreed upon provisions within this RFP including, but not limited to the form contract P-37 (attached hereto as Appendix F). The contract document will be submitted along with the proposal response. Following notification, the parties shall negotiate any outstanding provisions or changes to the proposed provisions and incorporate them accordingly into the referenced Exhibits A, B and C (Scope of Services, (“Services”), Contract Price/Price Limitation/Payment, and Special Provisions) as outlined in the form P-37.


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GENERAL TERMS YES NO

+ 6. PBM agrees to mid-year and annual face-to-face meetings with the State

to discuss plan performance, present utilization and financial results, etc. at PBM’s expense and provide quarterly reports electronically. At a minimum, the State expects that the Account Executive and the Pharmacist Account Executive attend these meetings.

7. PBM agrees to implement eligibility updates within 24 hours of receipt.

8. PBM agrees to provide biweekly (every 2 weeks) and/or monthly data

transmissions (may include feeds to data warehouses) to at least 5 chosen vendors at no charge, and four full, annual electronic claims files, in NCPDP format, at NO charge. PBM will also interact/exchange data with all vendors as needed at no additional charge.

9. The State will have the ability to adjust “refill-too-soon” limits at both

retail and mail without any modifications to the guaranteed pricing. Please note: The State currently wishes to maintain the current refill limits of 75% for all medications and 90% for opioids.

10. PBM agrees that all future edits required as a result of plan design changes

implemented by the State or its designee, and uploads therefore, shall be completed, after testing, by the PBM within 30 days of request/advisory by the State or its designee.

11. PBM agrees to provide detailed test claim samples/testing reports to insure accurate claims processing when plan changes are implemented.

CONTRACT DEFINITIONS YES NO

12. Contract Definitions

a. Hybrid Transparent – PBM agrees to pay participating pharmacies at the PBM’s contracted rate. In the event that the amount paid to the participating pharmacy does not equal the amount invoiced the State, the PBM may retain the difference. The PBM agrees to pass through 100% of ALL rebate revenue earned and will not charge an administrative fee for this arrangement. The PBM also agrees to disclose details of all programs and services generating financial remuneration from outside entities.

+

b. Rebates – Compensation or remuneration of any kind received or recovered from a pharmaceutical manufacturer attributable to the purchase or utilization of generic, brand, and specialty covered drugs by eligible persons, including, but not limited to, market share incentives; promotional allowances; commissions; educational grants; market share of utilization; drug pull-through programs; implementation allowances; clinical detailing; rebate submission fees; and administrative or management fees. Rebates also include any fees that the PBM receives from a pharmaceutical manufacturer for administrative costs, formulary placement, and/or access.


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+ c. AWP (Average Wholesale Price) – AWP will be based on date sensitive

(i.e., point of sale), 11-digit NDC as supplied by a nationally recognized pricing source (e.g., MediSpan) for retail, mail order, and specialty adjudicated claims.

+ d. Member Copay - Members will pay the lowest of the following: plan

copay, plan-negotiated discounted price, usual and customary (U&C), MAC (maximum allowable cost) or retail cash price. Excess copayment retention is not permitted.

+ e. Paid Claims - Defined as all transactions made on eligible members that

result in a payment to pharmacies or members from the State or State member copays. (Does not include reversals and adjustments.) Each unique prescription that results in payment shall be calculated separately as a paid claim.

+ f. Member - All eligible employees, retirees, and their eligible dependents enrolled under the State prescription benefit program.

g. State eligibility and claim data - All eligibility and claims records are the sole property of the State, and must be made available upon request to the State and its representatives. Selling of the State’s data to ANY outside entities must be approved in advance, reported on a monthly basis and all income derived must be disclosed and shared per agreement with the State. Even if PBM has not "sold" the data, they are NOT free to use the data for analyses that they publish or provide at a fee to outside industries.

h. GCN - A five-character numeric figure that represents the clinical

formulation; it is specific to active ingredient list, route of administration, dosage form, and drug strength.

+ 13. Minimum Brand and Minimum Generic Discount Guarantees for both

mail and retail shall be defined as follows: (1 - Aggregate Ingredient Cost/Aggregate AWP)

+ a. Aggregate Discounted Ingredient Cost prior to application of plan specific copayments will be the basis of the calculation.

+ b. Aggregate AWP will be from a single, nationally recognized price source for all claims. (Please indicate source.)

+ c. Dispensing Fees are not included in the Aggregate Ingredient Cost.

+ d. Zero balance due claims or zero amount claims will be included in the

guaranteed measurement for AWP, ingredient cost, achieved discounts or dispensing fee calculations at the discounted cost before copay.

+ e. All guarantee measurements shall be calculated prior to the copayment

being applied. Entire dollar-for-dollar shortfalls, prior to the application of copayments, will be reimbursed to the State without any adjustments to remove zero balance due or excess copayment claims.


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+ f. Both the Aggregate Ingredient Cost and Aggregate AWP from the actual date of claim adjudication will be used.

+ g. Aggregate AWP will be the date sensitive, 11-digit NDC of the actual product dispensed at both retail and mail and specialty.

+ h. Non-MAC, MAC, single-source, and multiple source generic products

are to be included in the generic guarantee measurement (regardless of the exclusivity period and/or number of manufacturers) and excluded from brand guarantee measurement.

+ i. Compounds, OTC claims, and claims with ancillary charges will be

excluded from the guarantee measurements for retail and mail order components.

+ j. The guarantee measurement must exclude the savings impact from DUR

programs, formulary programs, utilization management programs, and/or other therapeutic interventions.

+ k. Measurement will be performed annually via independent audit utilizing

date-sensitive AWP derived from a single, nationally recognized price source for all claims.

+ 14. PBM agrees to provide upon request any proprietary algorithms, hierarchy or other logic employed to define a prescription drug as generic or brand.

FINANCIAL – GENERAL YES NO

15. PBM will invoice the State twice monthly for claims and once monthly for the administrative services.

16. Confirm that if the State disputes all or a portion of any invoice, the State will pay the undisputed amount timely and notify the PBM in writing, of the specific reason and amount of any dispute before the due date of the invoice. The PBM and the State will work together, in good faith, to resolve any dispute. Upon resolution, the State or the PBM will remit the amount owed to the other party, if any, as the parties agree based on the resolution.

17. There are NO additional fees (beyond those outlined in the financial

section) required to administer the services outlined in this Proposal. Any mandatory fees, including clinical and formulary programs fees, must be clearly outlined in the Financial Section.

18. All fees include the cost of claims incurred/filled during the effective dates

of this contract regardless of when they are actually processed and paid (run-out).

19. PBM agrees to a review and negotiate the pricing applied to newly introduced generic drugs annually.


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20. PBM agrees to adjudicate prescription claims for compound medications with the same dispensing fees and logic associated with traditional claims.

21. All pricing will be effective and guaranteed for the term of the agreement

and will not include adjustments for claims volume shifts amongst the various provider channels (e.g., mail utilization rates decline or 90-day retail utilization increases).

22. Confirm all pricing will be effective and guaranteed for the term of the

agreement and will not be modified or amended if the State implements or adds a 100% member paid plan design such as a high deductible health plan/consumer-driven health plan option.

23. Confirm all pricing will be effective and guaranteed for the term of the

agreement and will not be modified or amended if the State’s membership decreases by 30% or less.

24. All fees will be based on approved paid claims as defined in 12.e. definitions (above in this section).

25. All applicable administrative fees will be on a per paid claim basis as defined in 12.e. definitions.

+

26. Each distinct pricing guarantee (including rebates) will be measured and reconciled on a component (e.g. retail brand, retail generic, mail order brand, mail order generic, specialty drugs at participating retail pharmacies, and specialty drugs at the PBM’s Specialty Pharmacy) basis only and guaranteed on a dollar-for-dollar basis with 100% of any shortfalls recouped by the State. Surpluses in one component will not be utilized to offset deficits in another component.

27. PBM will provide a financial reconciliation report within 60 days after the end of each measurement period, and the report will include the contractual and actual discounts and dispensing fees for each component (e.g., retail brands, retail generics, mail brands, mail generics, specialty drugs via Participating Retail Pharmacies, specialty drugs via the PBM’s Specialty Pharmacy).

+ 28. PBM agrees that any shortfall between the actual result and the minimum

guarantee will be paid, dollar-for-dollar, to the State within 90 days of the end of the measurement period.

29. PBM’s financial reconciliation that occurs after the end of the

measurement period will use the lower of the AWP pricing at the point of adjudication or the retroactive AWP pricing, if the pricing source the PBM uses issues retroactive AWP pricing for that annual reconciliation time period.


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+

30. No pricing submitted will be contingent on participation in any proposed clinical management programs, group medical or behavioral health programs proposed by you or any other vendor other than programs that are requested by the State. Further, the pricing guaranteed in the Financial Section of this RFP reflects a) the PBM’s broadest national network and b) the PBM’s broadest formulary (drug exclusions allowed) or preferred drug listing, without mandated utilization management unless otherwise authorized or requested by the State.

+ 31. No pricing will be contingent on specific utilization patterns. For

instance, pricing terms contingent on limited utilization in a specific geographic location (e.g., New Hampshire) is unacceptable.

32. PBM will NOT implement or administer or allow any program that results

in the conversion from lower discounted ingredient cost drug products to higher ingredient cost drug products without the prior written consent of the State or its designee.

+ 33. Mail order pricing and rebates will apply to all claims that adjudicate at mail regardless of days’ supply.

34. PBM agrees that mail order and specialty drug dispensing fees will remain

constant throughout the contract term and will not be increased for any increases in postage charges.

35. PBM will guarantee Retail/Mail Order unit cost equalization, meaning that Mail Order unit costs prior to member cost sharing, dispensing fees, and sales taxes charged to the State will be no greater than the unit cost for the same NDC-11 at Retail.

PBM agrees to produce a date-sensitive comparison report showing unit costs charged to the State at a GCN-level, and reimburse the State on a dollar-for-dollar basis for all instances where mail order unit costs exceed retail unit’s costs. Report and reconciliation will be provided on an annual basis.

36. The State will be notified of any switch in the AWP source at least 180

days prior to the change. In the event that the AWP source change is not determined by a third party to be price neutral for the State, the State will have the right to terminate the contract with no penalty.

37. PBM will be responsible for collecting any outstanding member cost

shares for prescriptions dispensed through the mail order facility. The PBM will not invoice the State for any uncollected member cost shares.

FINANCIAL – REBATES YES NO

+ 38. Guaranteed rebates per brand will be based on all brand prescriptions dispensed, not only on formulary prescriptions dispensed.

+ 39. Rebates are guarantees on a minimum (i.e., not fixed) basis, and the PBM will pass through 100% of the rebates through to the State.


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FINANCIAL – REBATES YES NO

+ 40. Over-performance of minimum rebate guarantees will not be used to offset performance guarantee shortfalls in other areas.

41. Rebates will not be withheld for execution of any contract amendments.

The State is entering into a three-year agreement and needs no annual renewals/amendments signatures for payment of rebates.

42. PBM will reconcile rebate guarantees to verify that the State is receiving

the guaranteed rebates and provide rebate payments and reports listing detailed rebate utilization and calculations to the State quarterly, within sixty (60) days of the quarter’s close, without a request being made by the State.

43. PBM will provide the annual rebate report within 90 days of the end of

each contract year. Any shortfall between the actual result and the minimum rebate guarantees will be paid, dollar-for-dollar, to the State within 90 days of the end of the contract year.

+ 44. All rebate revenue earned by the State will be paid to the State regardless

of its termination status as a client. Lag rebates will continue to be paid to the State after termination until 100% of earned rebates are paid.

45. PBM agrees to produce an auditable quarterly report demonstrating pass-

through rebates. PBM will attach a sample of the report they intend to use as part of their response.

FORMULARY MANAGEMENT YES NO

46. If requested by the State, the PBM agrees to grandfather the current

Express Scripts formulary (preferred) list and respective copayments for up to 90 days following the contract effective date with no impact on the minimum rebate guarantees.

47. With the exception of FDA recalls or other safety issues, the PBM agrees

not to remove any drug products, brand or generic, from the State’s formulary or preferred drug listing without notification and prior approval from the State.

48. PBM agrees to notify the State or its designee at least 90 days in advance when a formulary drug is targeted to be moved to or from the preferred/formulary drug list. PBM must provide a detailed disruption and financial impact analysis at the same time. No greater than two percent (2%) of participants will be disrupted by any formulary deletions or all deletions in total, on an annual basis.

49. PBM agrees to remove drugs from coverage or the formulary at most one-

time per year and no greater than two percent (2%) of participants will be disrupted by any formulary deletions or all deletions in total, on an annual basis.

50. No alterations to financial guarantees will be made on formulary drug exclusions.


31


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PHARMACY NETWORK MANAGEMENT YES NO

51. PBM will not withhold any financial recoveries from audits performed on

the contracted pharmacy network including mail order and specialty pharmacies. Any recoveries will be disclosed and credited to the State.

52. PBM agrees that it will not remove any participating network pharmacies

that impact greater than 2% of the State’s prescriptions without communicating to the State at least sixty (60) days in advance of the scheduled change. If the change is not agreeable to the State, the State will have the right to terminate the agreement without penalty.

53. PBM agrees to offer improved pricing terms to the State if greater than 2%

of members are impacted by proposed changes to the participating pharmacy network.

AUDITING & AUDIT RIGHTS YES NO

+ 54. PBM agrees that all financial pricing components (discounts, dispensing

fees, rebates) are subject to independent, electronic audit utilizing date sensitive AWP information on an NDC level from a nationally recognized pricing source (e.g., MediSpan).

55. The State or its designee will have the right to audit annually, with an auditor of its choice, (for both claims and rebate audits), with full cooperation of the selected PBM, the claims, services and pricing and/or rebates, including the manufacturer rebate contracts held by the PBM, to verify compliance with all program requirements and contractual guarantees with no additional charge from the PBM.

56. The State or its designee will have the right to audit up to 36 months of claims data at no additional charge from the PBM.

57. The State or its designee will have the right to audit, with an auditor of its choice, at any time provided the State gives 90-days advance notice.

58. PBM will provide complete claim files and documentation (i.e., full claim

files, financial reconciliation reports, inclusion files, and plan documentation) to the auditor within 30 days of receipt of the audit data request as long as a non-disclosure agreement is in place between the auditor and the PBM.

59. PBM agrees to a 30-day turnaround time to provide the full responses to all of the sample claims and claims audit findings.

60. PBM agrees to financial guarantees for turnaround times for each stage of the audit process.

61. PBM will correct any errors that the State, or its representative, brings to the PBM’s attention whether identified by an audit or otherwise.

62. The State or its designee will have the right to audit up to 12 pharmaceutical manufacturer contracts during an on-site rebate audit.


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AUDITING & AUDIT RIGHTS YES NO

63. The State’s right to audit shall survive the termination of the agreement between the parties for a period of 3 years.

64. The State will not be held responsible for time or miscellaneous costs incurred by the PBM in association with any audit process including, all costs associated with provision of data, audit finding response reports, or systems access, provided to the State or its designee by the PBM during the life of the contract. Note: This includes any data required to transfer the business to another vendor and money collected from lawsuits and internal audits.

LEGAL RESPONSIBILITIES YES NO

65. PBM shall indemnify, defend and hold harmless the State, its officers and employees, from and against any and all claims, actions, demands, costs, and expenses, including reasonable attorney fees and disbursements, as a result of a breach by the PBM of any of its obligations under the Agreement or arising out of the negligent act or omission or willful misconduct of the PBM or its employees or agents.

66. PBM agrees to hold the State harmless for any HIPAA Violations made by the PBM or its Network Pharmacies.

67. PBM will agree to defend claims litigation based on its decisions to deny coverage for clinical reasons.

68. PBM acknowledges that it is compliant with the electronic Data Interchange (“EDI”), Privacy and Security Rules of the Health Insurance Portability and Accountability Act (“HIPAA”), and will execute the appropriate Business Associate Agreement (“BAA”) as provided by the State (copy attached in Appendix G). PBM also agrees that in the event of a privacy violation or data breach, that the PBM will notify the State and the impacted members to a breach and provide any required remedies.

69. PBM agrees that this Agreement or any of the functions to be performed hereunder shall not be assigned by either party to another party, absent advance notice to the other party, and written consent to said assignment, which consent shall not be unreasonably withheld. In the event either party shall not agree to an assignment by the other party, then this agreement shall terminate upon the effective date of said assignment.

70. PBM agrees that in the event of a dispute between the parties, about the payment or entitlement to receive payment, or any administrative fees hereunder, the PBM and the State shall endeavor to meet and negotiate a reasonable outcome of said dispute. In NO event shall PBM undertake unilateral offset against any monies due and owed to the State, whether from manufacturer rebates, credit adjustment or otherwise.

71. PBM will respond to and incorporate future Health Care Reform changes in full compliance with the law and at no additional cost to the State.


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IMPLEMENTATION / TRANSITION YES NO

72. PBM agrees to load all current Prior Authorizations, open mail order refills, open specialty refills, claim history files, and accumulator files that exist for current members from the existing PBM at NO charge to the State no later than the date of implementation of management by the selected PBM. (NO charge includes no charges being deducted from the implementation allowance for file loading or IT.)

73. PBM agrees to send at least 12 months of claims history data, all current

prior authorizations, open mail order refills, specialty transfer files, and accumulator files that exist for the State participants to the next/successor PBM at NO charge if the State terminates the contract with or without cause.

74. PBM agrees to waive any charges to the State or the State’s medical plan

claims administrators such as a set-up fee, a programming fee or a monthly fee, for establishing a connection with a Third Party Administrator/Claims processor for real-time, bidirectional data integration, including non-standard data integration formats.

75. PBM agrees to absorb any programming or other administrative costs to meet any existing or future requirements of the Affordable Care Act.

76. PBM will provide draft SPD language for any clinical programs that are to be implemented.

77. PBM agrees to provide online, real time, claim system access to the State

or its designee, including access to historical claims data for up to three years following termination of the agreement.

78. PBM agrees to include a clause to the effect that, upon contract

termination, the cost of any work required by a new administrator to bring records in unsatisfactory condition up to date shall be the obligation of your firm and your firm shall reimburse such expenses.

MEMBER SERVICES YES NO

79. PBM agrees to obtain the State’s approval for all member communication materials before distribution to members.

80. The State reserves the right to review, edit, or customize any communication from the PBM to its membership.

81. PBM mail order service must notify individual participating members and

the State or its designee prior to substituting products that will result in a higher member copayment.

82. PBM agrees to duplicate the plan features and level of coverage presently offered to the State’s covered member population.

State of New Hampshire SECTION V

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SECTION V: FINANCIAL

This RFP requires pricing on a “hybrid transparent” basis with 100% of all rebate revenue being sent to the State. Rebates will be measured based on the minimum rebate guarantees.

Bids on a “pass through” discount model are acceptable; however, bids will be measured based on the minimum discount guarantees as requested in the RFP and not on estimated discounts.

Pricing shall be based on your Broadest Network.

Vendors are required to complete all financial exhibits as instructed. All administrative fees, program fees, and dispensing fees are required on a per-member-per-month or a per-prescription paid basis (as defined in Section IV – 12.e). Note that fees must be based on prescriptions dispensed (not adjustments, errors, or redo's).

All services covered under the fee should be listed.

ALL FEES ARE BINDING UNTIL THE IMPLEMENTATION DATE (JANUARY 1, 2019) SPECIFIED IN THIS PROPOSAL AND MUST REMAIN GUARANTEED FOR THE FULL 3-YEAR CONTRACT TERM.


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ADMINISTRATIVE FEES

The State requires the completion of the following Administrative Fee table and questions:

1. Complete the following Administrative Fee Table

HYBRID TRANSPARENT PROPOSAL ADMINISTRATIVE SERVICES CY 2019 CY 2020 CY 2021

PBM Core Services $ _____ per Rx $ _____ per Rx $ _____ per Rx

Vaccine Services $ _____ per Rx $ _____ per Rx $ _____ per Rx

Paper Claims $ _____ per Rx $ _____ per Rx $ _____ per Rx

E-Prescribing $ _____ per Rx $ _____ per Rx $ _____ per Rx

Electronic Prior Authorizations $ _____ per Rx $ _____ per Rx $ _____ per Rx

Indicate which of these services are included for no additional cost: Toll Free Phone Lines Y or N Y or N Y or N

Monthly Data Feeds to State/Designee(s) Y or N Y or N Y or N Prospective /Concurrent/Retro DUR Y or N Y or N Y or N

Standard Reports Y or N Y or N Y or N

Ad Hoc Reports Y or N Y or N Y or N

COB Program Y or N Y or N Y or N Mandatory Mail Program with Opt-Out Y or N Y or N Y or N

Dose Optimization Program Y or N Y or N Y or N

Prior Authorization Program Y or N Y or N Y or N

Step Therapy Program Y or N Y or N Y or N Quantity Limitations Y or N Y or N Y or N

Custom System Overrides Y or N Y or N Y or N

Annual EOB Statements Y or N Y or N Y or N

Retro Termination Letters Y or N Y or N Y or N Group Coding Y or N Y or N Y or N

Drug Notification Letters Y or N Y or N Y or N

Formulary Administration/Management Y or N Y or N Y or N

ID Cards Y or N Y or N Y or N Access to Pharmacy Directories and other member materials

Y or N Y or N Y or N

Standard 1st level appeals processing Y or N Y or N Y or N

Standard 2nd level appeals processing Y or N Y or N Y or N

Urgent appeals processing Y or N Y or N Y or N

Overrides Y or N Y or N Y or N


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HYBRID TRANSPARENT PROPOSAL ADMINISTRATIVE SERVICES CY 2019 CY 2020 CY 2021

Audit Recovery Fees Y or N Y or N Y or N Compound Drug Management Y or N Y or N Y or N

Services not included in fees above (i.e., services marked “N” above) (show fees separately):

•

•

Other Services (show fees separately):

•

•

ADMINISTRATIVE FEE QUESTIONS VENDOR RESPONSE

2. Detail all services and supplies to be provided under your basic fees that are not included in your response to the chart in question 1.

3. Confirm you agree to guarantee your quoted fees until the assumed implementation date.

4. Confirm fees quoted are not contingent upon any of the following:

• Minimum enrollment or utilization requirements.

• Participation in any supplemental programs.

• Direct communication with patient population.

5. Confirm postage is included in ID card generation, duplicate cards, all mail order prescriptions, and any mailings.

6. Confirm quoted fees include postage paid mail order envelopes for member prescription submission.

7. Confirm your organization agrees that all costs for audits, recoveries, collections, and data feeds submitted to the State or their designee will be absorbed by the PBM during the life of the contract. This includes any data required to transfer the business to another vendor and money collected from lawsuits and internal audits.

8. Confirm that multi-language communication phone line support be included in the base administrative fee.


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ADMINISTRATIVE FEE QUESTIONS VENDOR RESPONSE

9. Confirm disabled (e.g., hearing-impaired) member calls will be facilitated through your member services area.

10. Will there be any additional charges if the plan of benefits is restructured or new classes of eligible members are added? If so, how are these charges determined and state amount of charges?

11. Detail all data related services included under the base administrative fees including ad hoc reporting, electronic claims files, plan design options, custom mailings, etc.

12. Detail any data related service fees not included in the base administrative fees.

13. Do you have a contractual relationship with third party administrators/ organizations in which you pay service fees? If so, identify the outside organizations that receive these service fees and explain the nature of the relationship.

14. Pricing shall be based on your Broadest Network EGWP ADMINISTRATION FEE

Review the requested services in “Section VIII.I–Medicare Part D EGWP Program” and provide a per-Part D eligible member-per-month fee for EGWP services.

Employer Group Waiver Plan (EGWP) Fee Part-D Eligible

Member PMPM Fee

PBM submits all required reporting to CMS $0.00

1. Provide a detailed list of all services included in the above fee.

2. Describe all services not included in the above quoted fee.


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PRESCRIPTION DRUG PRICING

AWP Reimbursement Basis - Complete the following tables using the drug reimbursement that your organization is willing to guarantee on a dollar-for-dollar basis for each year of the contract. Columns marked "AWP Discount" are to be completed using discount from 100% AWP and dispensing fee logic. All guarantees must be based on the AWP unit cost dispensed at the point of sale.

1. CY 2019

Broad Retail Network AWP Discount Retail Supply Up to 31 days

AWP Discount Retail Supply 32-90 days [Use if applicable]

AWP Discount Mail Supply

1-90 days

Commercial Plans

Brand Drugs2

Discount from AWP for all brands % % %

Dispensing Fee Per Rx $ ____ per Rx $ ____ per Rx $ ____ per Rx

Generic Drugs3

Discount from AWP for all generics (composite discount of MAC and Non-MAC prices, discounted AWP, or usual and customary retail price)

% % %


Rebates

Minimum Guarantee Per Brand $ ____ per brand $ ____ per brand $ ____ per brand

EGWP Plan

Brand Drugs2



Generic Drugs3


% % %


Rebates


2 Including both single source and multi-source brands. 3 Including single-source generics.


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2. CY 2020




1-90 days

Commercial Plans

Brand Drugs4



Generic Drugs5


% % %


Rebates


EGWP Plan

Brand Drugs4



Generic Drugs5


% % %


Rebates




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3. CY 2021




1-90 days

Commercial Plans

Brand Drugs6



Generic Drugs7


% % %


Rebates


EGWP Plan

Brand Drugs6



Generic Drugs7


% % %


Rebates




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4. Confirm the pricing listed in the tables 1 to 3 above reflects:

PROPOSED PRICING VENDOR

RESPONSE

All guarantees are calculated using the date sensitive AWP based on the 11-digit NDC of the actual product dispensed

All-in generic guarantee inclusive of single-source generics

Drugs with an “Insufficient Supply” are included in the guarantees

Select, sole source or authorized generics from at least one FDA-approved generic manufacturer with exclusivity or limited availability, supply or competition will be included in the generic pricing guarantees and excluded from the brand pricing guarantees.

No single-source generic or generic drug will be included in the brand drug component for the annual discount guarantee reconciliation.

Member Cost Share at the point-of-sale (for retail and mail) is based on the lowest of the plan copay/coinsurance, usual and customary charges, negotiated discounted ingredient cost plus dispensing fee or retail cash price

All guarantees are calculated before the application of member cost share All guarantees (including Rebates) are stand-alone with no offsetting (within or across channels)

Any guarantee shortfalls are paid on a dollar-for-dollar basis

Confirm that the State’s current plan designs qualify for the proposed rebate guarantees. Please give the name of the qualifying rebate guarantee class (if applicable).

5. Provide your proposed source for AWP (average wholesale price) data.

6. How often are AWP prices updated in your adjudication system?

7. Provide your proposed drug type designation or classification (e.g. brand, generic) source (i.e. First DataBank, Medi-Span, Redbook, Other). If other, please specify.

SPECIALTY PHARMACY PROGRAM PRICING The State currently has an exclusive specialty arrangement and is willing to continue this arrangement into its next PBM contract if it is advantageous for the Plan and its member. 1. Please provide your organization’s definition and qualification criteria of a “specialty drug product.”

2. Provide an AWP-based pricing list of all specialty pharmaceuticals that your company dispenses and distributes to providers and patients. Your pricing must include adequate supplies of ancillaries such as needles, swabs, syringes, and containers. The following items must be included in your list:

a. Product Name

b. Therapeutic Group/Therapeutic Category

c. Guaranteed Minimum AWP discount for all specialty pharmacy program prescriptions for the exclusive specialty arrangement.


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3. AWP Reimbursement Basis – Complete the following table using the drug reimbursement that your organization is willing to guarantee on a dollar-for-dollar basis for each year of a contract. Please complete "AWP Discount" using discount from 100% AWP and dispensing fee logic.

a. Complete the following table under the proposed exclusive specialty arrangement:

Specialty Drugs Dispensed at Participating Retail Pharmacies CY 2019 CY 2020 CY 2021

Overall Effective Discount (OED) Guarantee from AWP % % %

Confirm New to Market Specialty Drugs and New to Market Limited Distribution Specialty Drugs will be included in the above OED guarantee

Dispensing Fee Per Rx $___ per Rx $___ per Rx $___ per Rx

Administrative Fee Per Rx $___ per Rx $___ per Rx $___ per Rx

Rebate - Minimum Guaranteed Per Brand $___ per brand $___ per brand $___ per brand

b. Complete the following table:

Specialty Drugs Dispensed at the PBM’s Specialty Pharmacy CY 2019 CY 2020 CY 2021

Overall Effective Discount (OED) Guarantee from AWP % % %

Confirm New to Market Specialty Drugs and New to Market Limited Distribution Specialty Drugs will be included in the above OED guarantee

Dispensing Fee Per Rx $___ per Rx $___ per Rx $___ per Rx

Administrative Fee Per Rx $___ per Rx $___ per Rx $___ per Rx

Rebate - Minimum Guaranteed Per Brand $___ per brand $___ per brand $___ per brand

4. Please describe any price inflation guarantee you are putting forth for specialty drugs.

5. Are your proposed guarantees for your retail/mail program contingent upon the State’s purchase of your specialty drug program?

6. Confirm that your specialty program will limit specialty claims to a 30-day supply.

ALLOWANCES

Please complete the following table:

ALLOWANCE DESCRIPTION VENDOR RESPONSE

Implementation Place the dollar ($) per member amount or the flat dollar $_____


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Allowance amount you are offering the State

Pre-Implementation Audit Allowance*

PBM will agree to reimburse the State for the expense of a Pre-Implementation Audit (up to $35,000) to be conducted at least 60 days prior to the start of or change to claims adjudication.

General Pharmacy Program Management

Place the dollar ($) per member amount or the flat dollar amount you are offering the State for general expenses related to the management of the pharmacy benefits program such as pharmacy claim and rebate audits, communication expenses, clinical programs, consulting fees or be used as a credit against claim invoices.

$_____

* As indicated in Section III.D, the State intends to hire a firm to conduct a pre-implementation audit to

ensure that the State’s plan designs and financial terms are programmed correctly in the Contractor’s claims system and the claims are being correctly adjudicated. The State will not be charged by the Contractor for this audit process.

The State requests that Vendor’s provide a pre-implementation audit allowance to reimburse the State for any expenses incurred for conducting such audit.


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GENERIC DRUGS - DISPENSING RATES 1. Complete the table below for contract Years 1, 2, and 3. Note that generic dispensing rate includes only true

instances of generic dispensing (i.e., excluded are multi-source brand drugs dispensed under member-pay-difference plan designs).

Guaranteed GDR Retail ≤ 31 days Mail Order

CY 2019 % %

CY 2020 % %

CY 2021 % %

2. What dollar amount are you prepared to put at risk for failure to meet your GDR guarantee?

3. Confirm the PBM’s Generic Dispensing Rate Guarantee will be measured and reconciled on a component basis and a shortfall in one delivery channel will not be used to offset a shortfall in another delivery channel.

RIGHT TO REMOVE OR ADD SERVICES

IMPORTANT NOTE – The State reserves the right to remove services from the pharmacy administration contract. If your proposed financial terms and fees would be different if any of the following plans are removed from the contract, you must complete additional copies of the financial exhibits reflecting the different terms and fees.

Possible plans removed from pharmacy administration contract

Indicate which of the two scenarios below applies

Proposed financial terms and fees unchanged

Proposed financial terms and fees change and alternative terms are

included Non-Medicare Retiree Plan

Medicare (EGWP) Retiree Plan

State of New Hampshire SECTION VII

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SECTION VI: PERFORMANCE GUARANTEES

The State requires vendors to agree to place a minimum amount of $400,000 per contract year at risk for performance guarantees.

The exhibit below identifies the specific performance guarantees that are the basis of performance responsibilities for any resulting contract.

Vendors are encouraged to place at risk a greater amount than the minimum of $400,000 per contract year; a vendor’s willingness to offer meaningful guarantees (greater than the minimum) will be reflected in their score.

Performance guarantee metrics may be self-reported, but are subject to independent audit by the State. All guarantees shall be set and measured annually.

Provide the total amount per contract year at risk for performance guarantees. At time of contract, the parties shall mutually agree to the allocation of the at risk funds.

Performance Guarantee Total Amount at Risk

Implementation Indicate the Total Implementation Performance Guarantees Amount you are proposing to the State. $_____________

Ongoing (annual) Indicate the Total Ongoing Annual Performance Guarantees Amount you are proposing to the State (at least $400,000). $_____________

Ongoing (annual) PBM agrees the State may allocate its preferred weighting (e.g., 0% to 30%) for the Performance Guarantees below prior to the start of each Contractual Year.

Yes / No

You are required to respond to each performance guarantee by indicating your organization’s willingness to agree to each performance guarantee and the requested measurement basis (State account specific performance or the vendor’s book-of-business performance). Vendors are strongly encouraged to agree to provide guarantees on the State account specific performance for the majority of the measurements. Using a book-of-business measurement for many of the guarantees diminishes or eliminates their value to the State and this will be reflected in the vendor’s score.

Standard

Requested Measurement

Basis

Confirm Your Willingness to

Guarantee [Yes/No]

Implementation Performance Guarantees Clean Implementation

No systems errors, ID card delays, and the State online access to all tools prior to

effective date

State account specific

Implementation Timeline

Implementation team will be assigned and introduced to the State within 5 business days

of G&C approval


Implementation Team

Implementation team members will not change and will be responsible for the accurate installation of all administrative,



47

Standard


Basis


Guarantee [Yes/No] clinical and financial parameters for the State’s program

ID Card Mailing All ID cards will be mailed at least 10 days prior to the effective date and will be 100% accurate (provided that a valid eligibility file was received at least 15 days prior to the effective date)


Implementation Satisfaction Scorecard

Assigned Account Executive will work with the State prior to the start of implementation to agree on terms of a satisfaction scorecard to be issued to the State after effective date for completion


Ongoing (Annual) Performance Guarantees Payment Accuracy & System Performance

Protected Health Information (PHI)

PBM guarantees no incidents in violation of HIPAA Security Rules which results in a transmission of electronic PHI for the State's covered members.


Plan Design Change Administration Accuracy

Implementation of all plan design changes will be 100% accurate.


Pricing Change Accuracy

Implementation of all pricing changes will be 100% accurate.


Financial accuracy Percentage of claim payments made without error relative to the total dollars paid will be at least 99%


Mail Service Non-Financial Accuracy

The mail service pharmacy shall guarantee dispensing accuracy of at least 99.996% (correct participant name, correct participant address, correct drug, correct dosage form, and correct strength)


System Downtime At least 99.5% access to its systems by all the retail pharmacies in PBM’s network 24 hours a day, 7 days a week, 365 days a year


Claims Eligibility Data

Eligibility loads not to exceed 24-hours after receipt


Eligibility Data Error Reporting

Eligibility file error reporting on all eligibility file updates will be provided to the State within 2 business days


Eligibility Error Error rate identified through quarterly audits State account


48

Standard


Basis


Guarantee [Yes/No] Rate Audits shall not exceed, on an average basis, 2%.

This is measured and reported on a quarterly basis.

specific

Invoicing Errors All invoicing errors will be credits back to the State by next billing cycle or PBM will pay interest


Account Management

Contract Drafting Cooperation

Response to recommended contract language changes within 10 business days.


State Approval of Member Communications

100% of all member communications will be approved by the State – exceptions for drug recalls and urgent patient safety communications


Member communication mailing errors

100% of all member communications shall be accurate. Should a mailing be sent in error or contain erroneous information regarding any aspect of the plans administration the vendor shall pay a penalty per erroneous document.


Delivery of Standard Reports

Within 30 days of end of reporting quarter State account specific

Accuracy of Standard Reports

All standard reports provided will be 100% accurate.


Pharmacy Audit Resolution

Within 6 months of identification and notification to PBM by the State or its designee


PBM Account Teams Performance

The State may assess a penalty per Contract Year if, after the first Contract Year and each successive Contract Year, the State’s benefits staff do not rate PBM account team’s performance for such Contract Year an average of 3 or better on a scale of 1 to 5 (5 being the best based on a range of performance criteria agreed to between the State and PBM at the beginning of such Contract Year)


Account Management Turnover

Account team members will remain constant for at least the first 18 months of the contact period, unless a change in account management staff is requested by the State.



49

Standard


Basis


Guarantee [Yes/No]

Member Services

Mail Turnaround – Prescriptions not requiring intervention

95% of prescriptions dispensed within average of 2 business days and 100% within average of 3 business days


Mail Turnaround – Prescriptions requiring intervention

95% of prescriptions dispensed within average of 4 business days and 100% within average of 5 business days


Paper Claims Turnaround

95% of prescriptions reimbursed within average of 10 business days and 100% within average of 14 business days.


ID Cards Mailing 98% of all ID cards are sent within 5 business days of receipt of eligibility. 100% mailed within 10 business days.


Replacement ID Card Mailing

Standard replacement ID cards will be produced within an annual average of five (5) business days of the request.


Mailing Member Materials

All applicable member materials (for example, mail order forms) will be mailed at least 10 days prior to the effective date and will be 100% accurate (provided that eligibility file was received at least 30 days prior to the effective date).


Phone Average Speed of Answer

100% of calls to State-specific toll free line shall be answered within 20 seconds (excluding IVR).


Phone Abandonment Rate

100% of calls to the State-specific toll free line shall be answered with an abandonment rate of 3% of less


Written Inquiry Answer Time

95% of inquiries responded to in 5 business days – 100% in 20 business days



50

Standard


Basis


Guarantee [Yes/No]

Member Satisfaction Survey

The PBM agrees to conduct a Member Satisfaction Survey for each contract year and that the Satisfaction Rate will be 90% or greater. A yearly penalty may be assessed against the PBM for failure to meet this standard. “Member Satisfaction Rate” means (i) the number of Eligible Persons responding to PBM annual standard Patient Satisfaction Survey as being satisfied with the overall performance under the Integrated Program divided by (ii) the number of Eligible Persons responding to such annual Patient Satisfaction Survey; the State must provide timely approvals and responses, and a minimum of 20% of surveys must be returned for the Performance standard to be applicable.


Issue Resolution: Verbal Inquiries

PBM will resolve 99% of all telephone issues at the first point of contact (the number of telephone inquiries completely resolved at the time of initial contact divided by the total number of calls)


Issue Resolution: Written Inquiries

PBM will resolve 98% of all written inquiries within 10 business days of receipt of inquiry


Issue Resolution: State Staff Involvement / Escalation

PBM will resolve member issues within 48 business hours for any case that required the involvement of the State’s staff due to incorrect or incomplete information being provided by the PBM. If not resolved within 48 hours, a penalty will be applied per case, up to an annual maximum.


Retail Pharmacy Retail Pharmacy Audit

100% of participating retail pharmacies will be subject to automated review audits and 20% of participating pharmacies will be subject to further investigation (e.g., desk audits, on-site audits, etc.) as a result of the automated review audits.

Book of business

Retail Pharmacy Turnover

Less than 5% of retail pharmacies will leave the retail network.

Book of business


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Standard


Basis


Guarantee [Yes/No]

Reports Ad-hoc Reports A minimum of 90% of Ad-hoc reports will

be delivered to State within 7 business days of the request. Ad-hoc reports are defined as reports that are not part of the vendor’s standard reporting package


Standard Reports A minimum of 95% of standard reports will be delivered to the State within 3 business days of the request.


Online Reporting Data Availability

Online reporting data will be available within an annual average of fifteen (15) business days after the billing cycle that contains the last day of the month.


Claims Detail File All claims detail files sent to external vendors will be provided within 8 days of request or scheduled delivery date.


Audits Provide Data Extract requested

Within 30 days of request date or within 10 business days of executed confidentiality agreement (whichever occurs first).


Provide Data Extract requested

Within 30 days of request date or within 10 business days of executed confidentiality agreement (whichever occurs first).


Provide Complete Response to Data Request

Within 30 days of request. State account specific

Responding to Data Reconciliation Requests

Within 10 business days of request. State account specific

Providing Initial Response to Audit Findings

Within 30 days of receipt of findings. State account specific


52

SECTION VII: REQUIRED PROTECTION OF CONFIDENTIAL INFORMATION AND

DATA SECURITY

This section includes expectations on how the State’s confidential information will be protected by its Business Associate(s) as well as required contract language and required insurance coverage levels.

Confidential Information. In performing its obligations under the Agreement, and applicable Business Associate Agreement (“BAA”), the Business Associate, inclusive of any subsidiaries and any related entities (“BA”) shall gain access to information of the State, including personal health information (PHI) personally identifiable information (PII), and other personal, private, and/or sensitive information, hereinafter collectively referred to as “Confidential Information.” The BA shall not use the State’s Confidential Information developed or obtained during the performance of, or acquired, or developed by reason set forth within the Agreement and applicable BAA, except as is directly connected to, and necessary for, the BA’s performance under the Agreement, or unless otherwise permitted under the Agreement and/or applicable BAA.

Data Protection. Protection of Confidential Information which may be provided to the BA as part of the Agreement and applicable BAA shall be an integral part of the business activities of the BA. The BA shall ensure that there is no inappropriate or unauthorized use of the State’s information at any time. To this end, the BA shall develop and implement policies and procedures to safeguard the confidentiality, integrity and availability of the State’s information. The BA also will comply with the following terms and conditions:

a) Confidential Information obtained by the BA shall become and remain property of the State and shall at no time become the property of the BA unless otherwise explicitly permitted under the Agreement and applicable BAA;

b) At no time shall any data, information, or processes which either belong to, or are intended for the use of, the State be copied, disclosed, or retained by the BA, or any party related to the BA by business (subcontractor) for subsequent use in any transaction that does not relate to the delivery of Services to the State (See the applicable BAA);

c) The BA shall not provide any information collected in the connection with the provision of Services under the Agreement and applicable BAA for any purpose other than performing its obligations to provide the contracted Services, unless otherwise explicitly permitted under the Agreement;

d) In the event that the BA stores Confidential Information, including but not limited to PHI, and PII, this data shall be encrypted by the BA while both at Rest or in Motion.

The BA shall have proper security measures in place for the protection of the State’s data. The BA shall also ensure that any BA subcontractor(s) has proper security measure in place for protection of the State’s data. Such security measures shall comply with the HIPAA Privacy Rule, Standards for Privacy of Individually Identifiable Health Information, HIPAA Security Rule, Security Standards for the Protection of Electronic Protected Health Information, the Health Information Technology for Economic and Clinical Health Act (“HITECH), and all other applicable data protection and privacy laws, including privacy laws of the State of New Hampshire and any other applicable state, which may apply now or in the future.

Controls. The BA shall, and shall ensure that any subcontractor(s) used by the BA shall, have, maintain, and use at all times proper controls for secured storage of, limited access to, and rendering unreadable prior to discarding, all records containing the State’s Confidential Information, including but not limited to PHI, and PII. The BA shall not store or transfer Confidential Information collected in connection with the services rendered under this Agreement outside of the North America. This includes backup data and disaster recovery locations.


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Data Breach Notification. The BA shall, and shall ensure that any subcontractors used by the BA shall, inform the State of any security breach, or potential breach, that jeopardizes, or may jeopardize the State’s data or processes (i.e. any “Security Incident”). For purposes of reporting under this Section, the definition of a Security Incident shall be limited to the successful unauthorized access, use, disclosure, modification, or destruction of information, or the interference with system operations in an information system, and/or the potentially successful unauthorized access, use, disclosure, modification or destruction of information, or the potential interference with systems operations in an information system.

Notification of a data breach, or potential data breach, shall be given to the State within 24 hours of its discovery by the BA or the BA’s subcontractor(s). Full disclosure of the Security Incident shall be made and include all available information. The BA shall cooperate fully with the State, including but not limited to: make efforts to investigate the causes of the breach or potential breach; promptly take measures to prevent any future breach; and minimize any damage or loss resulting from the breach, or potential breach. In addition, the BA shall inform the State of the actions it is taking, or will take, to reduce the risk of further loss to the State. HIPAA Breach Notification Rule, 45 CFR §§ 164.400-414, the Federal Trade Commission’s Health Breach Notification Rule 16 CFR Part 318, and RSA 359-C:20 require public breach notification to individuals whose information has been or may be misused. All legal notifications required as a result of a breach of information, or potential breach, collected pursuant to this Contract shall be coordinated with the State. The BA shall ensure that any subcontractors used by the BA shall similarly notify the State of a data breach, or potential data breach within 24 hours of discovery, shall make a full disclosure, including providing the State with all available information, and shall cooperate fully with the State, as defined above.

Data Security Breach Liability. In addition to the BA’s obligations as set forth in the form contract P-37 (attached hereto as Appendix F) and the Business Associate Agreement (attached hereto as Appendix G) if the BA , or any subcontractor(s) used by the BA, is determined by any forensic analysis or report, to be the likely source of any loss, disclosure, theft or compromise of State’s data or information, and regardless of the BA’s belief that the BA, or subcontractor used by the BA, has complied with all data Security and Breach rules, or any other security precautions and is not responsible for the assessments, fines, losses, costs, and penalties and reimbursements resulting from said loss, the State shall recover from the BA all costs of response and recovery resulting from the Breach or potential Breach, including but not limited to: credit monitoring services, mailing costs and costs associated with website and telephone call center services that are necessary due to the Breach or potential Breach.

Data Breach Insurance. In addition to the BA’s insurance obligations as set forth in the form contract P-37 (attached hereto as Appendix F), the BA shall carry Data Security & Cyber Insurance coverage for unauthorized access, use, acquisition, disclosure, failure of security, breach of confidential information, of privacy perils, in an amount not less than $10 million per annual aggregate, covering all acts, errors, omissions, at minimum, during the full term of this Agreement and the applicable BAA. Such coverage shall be maintained in force at all times during the term of the Agreement and applicable BAA and for a period of two years thereafter for services completed during the term of the Agreement and consistent with the governing BAA. The State shall be given at least thirty (30) calendar days’ notice of the cancellation or expiration of the aforementioned insurance for any reason, at the address provided in the P-37.

Data Recovery. The BA shall be responsible for ensuring backup and redundancy of the State’s data, including but not limited to Confidential Information for recovery in the event of a system failure or disaster event within the BA’s data storage system(s) and/or a BA subcontractor(s)’ data storage system(s).

Process upon Conclusion/Termination of Services. At the conclusion of the Agreement, either through completion or termination, the BA shall implement an orderly return of State’s data in a format defined by the State at no additional cost to the State. At the State’s request, the BA shall destroy all data in all forms. Data shall be permanently deleted and not recoverable according to National Institute of Standards and Technology


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approved methods. The BA shall provide State with certificates of destruction and/or certificates verifying that all information has been returned and none retained.

Destruction /Disposal of State’s Data. Upon termination of the Agreement and applicable BAA for any reason, the BA, with respect to any Confidential Information, including but not limited to PHI, or PII, either received from the State, or created, maintained, or received by the BA on the State’s behalf, shall:

a) Where feasible, return or destroy the Confidential Information the BA still maintains in any form, at the sole discretion of the State, except where certain types of information must be retained for the State’s benefit, such as records of actuarial determinations, which will be maintained as agreed upon by the State;

b) Continue to use appropriate safeguards as identified in the Data Protection provisions above with

respect to any Confidential Information that is retained as agreed upon by the BA and the State;

c) Not use or disclose Confidential Information retained other than for purposes for which such information has been retained, and subject to the same terms and conditions as set forth in the original Agreement and/or BAA, as amended in writing, by both parties, if applicable.

Access to System Logs. The BA shall allow the State access to system security logs, latency statistics, etc., that affect the Agreement and applicable BAA, the State’s data and/or processes. This includes the ability of the State to request a report of the records that a specified user accessed over a specified period of time.

Import/Export Data. The State shall have the ability to import or export data in piecemeal manner or in its entirety at its discretion without interference from the BA and with the BA’s assistance, at no additional cost to the State. Notification of Governmental Authorities. With respect to instances in which the BA, or BA subcontractor(s) consider notifying Governmental Authorities concerning civil acts, the BA or BA subcontractors shall notify the State in writing and consult with the State prior to making any such notification; and immediately endeavor in good faith to reach agreement on the need and nature of such notification. If such agreement cannot be reached within seventy-two (72) hours after the BA, or BA subcontractor(s) has provided the State with written notice, the BA or BA subcontractor(s) shall have the right to inform Government Authorities solely to the extent required by applicable law. Damages in the event of a breach or potential breach: A Security Incident, including a potential breach, or potential privacy-related compliance issue, may cause the State irreparable harm for which monetary damages would not be adequate compensation. In the event of such a Security Incident, the State is entitled to seek equitable relief, including a restraining order, injunctive relief, specific performance and any other relief that may be available from any court, in addition to any other remedy to which the state may be entitled at law or in equity. Such remedies shall not be deemed exclusive, but shall be in addition to all other remedies available at law or in equity, subject to any express exclusion or limitations in the Agreement to the contrary. This Section VII Required Protection of Confidential Information and Data Security shall survive termination or conclusion of the Agreement and applicable BAA.

State of New Hampshire SECTION VIII

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SECTION VIII: TECHNICAL QUESTIONNAIRE ORGANIZATIONAL STABILITY & EXPERIENCE A.

Respond to the following questions:

ORGANIZATIONAL STABILITY & EXPERIENCE VENDOR RESPONSE

1. Provide the latest annual report, financial statement, SSAE 16 or SAS 70 type II, and other financial reports that indicate the financial position of your organization. From these documents, please provide the following:

a. Current ratio b. Debt to equity ratio

2. Complete the following table: a. Parent Company b. Year PBM Established c. Total Number of Covered Lives (CY 2017)

% from top 10 clients (CY 2017) Total Number of Covered Lives (CY 2016)

d. Total Number of Scripts Dispensed (CY 2017) e. Total AWP Dollars Processed (CY 2017) f. Total Number of Clients (CY 2017) g. Number of Group Plans Terminated in Past 12 Months

3. Provide the total number of years of direct PBM experience for the lead Account Manager, Financial Services, and Clinical staff assigned to this account. Provide a resume for each.

4. Indicate the number of any outstanding legal actions pending against your organization.

Can you assure the State these actions will not disrupt business operations?

5. What general and professional liability coverage do you currently have in place for the entity that is bidding to protect the State from losses or negligence?

Describe the type and amount of the fidelity bond insuring your employees that would protect the State in the event of a loss.


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ADMINISTRATIVE, MEMBER & CLAIM PAYING SERVICES B.

Confirm you agree to the following service specifications:

ADMINISTRATIVE, MEMBER & CLAIM PAYING SERVICES VENDOR CONFIRMATION

1. The State chooses to be invoiced on a bi-weekly (every two weeks) basis for the prior two weeks of claims to be paid via electronic wire with the State as the originator of the transaction. However, the State will accept invoicing on a semi-monthly (twice a month) basis for the prior two weeks (approximately) of claims. The State would agree to make payment within five business days of receipt of the invoice. Confirm you agree to this arrangement.

2. The State chooses to be invoiced on a monthly basis for administrative costs for the prior month to be paid via electronic wire with the State as the originator of the transaction. The State would agree to make payment within five business days of receipt of the invoice. Confirm you agree to this arrangement.

3. Confirm you agree to send quarterly reports electronically as well as present mid-year and annual meetings in person with the State to discuss plan performance, present financial results, etc.

4. Confirm you provide automated services that are available 24/7.

5. Confirm you agree to attend open enrollment meetings and other meetings as requested by the State.

6. Confirm you will provide dedicated clinical, account management, and customer service staffing to the State. The State requires that the vendor assign individuals to the State Plan for account management and clinical support on a regular and ongoing basis. The State requires that the vendor’s customer service team also be assigned to the State Plan and have the appropriate knowledge of the State’s plans of benefits. It is understood that these individuals may be assigned to other plans.

7. Confirm that you provide a live person to answer the customer service phone lines 24 hours per day, seven days per week. An option to speak to a representative as part of an interactive voice response system is acceptable.

8. Confirm you will offer the State’s staff online access to information and services via the Internet or through CRT interface.

9. Confirm you have the ability to produce temporary ID cards and/or proof of benefits in “real time”.

10. Confirm your organization will send recovery letters to members who continue to use their drug card after their termination.

11. Confirm you provide member support services for selecting and/or locating network pharmacies.


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ADMINISTRATIVE, MEMBER & CLAIM PAYING SERVICES VENDOR RESPONSE

1. Confirm that no penalties or interest will be charged to the State for late funding/payment.

2. For the customer/member service center proposed for the State provide the following:

a. Location of the call center b. Days of Operation c. Hours of Operation

3. For the customer/member service center proposed for the State provide the following for CY 2017:

a. Percent of calls abandoned b. Percent of calls handled by live representative c. Number of seconds to reach a live customer

service representative

4. How do you track member complaints? List the top 5 member complaints related to retail, mail order, and the specialty pharmacy program.

What processes/ remedies have been put into effect to resolve these complaints?

5. All member service call recordings and notes between the PBM and the State’s members will be the State’s property.

6. PBM agrees to document 100% of the State’s member service calls through call recordings and call notes. PBM will forward call recordings, written transcripts, and call notes at the State’s request within two business days of the request being made.

7. PBM agrees to provide the State with a dummy login to access the PBM’s member website prior to the go-live date.

8. PBM will provide the State with a virtual tour of its CSR system and any custom messaging system.

9. PBM will not automatically enroll the State in any programs that involve any type of communications with members or alterations of members’ medications, without express written consent from the State.


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ADMINISTRATIVE, MEMBER & CLAIM PAYING SERVICES VENDOR RESPONSE

10. The PBM agrees to, at minimum, quarterly calls to review member service issues. The PBM agrees to allow the Fund to review member service quality issues to the resolution endpoint.

11. The PBM agrees to a minimum of one annual meeting with call center executives to discuss services regarding enrollment and member issues.

12. Can you produce replacement ID cards within 24 hours, if necessary?

13. Do you currently perform membership satisfaction surveys? Provide a copy of the latest results of the survey. What percent of members indicated that they were “satisfied or very satisfied” with the overall program?

14. How do you remind members regarding refills and compliance? Indicate methods and frequency of interventions.

15. How often is the Internet directory updated? 16. What services are available to members via the

Internet? Provide detail regarding current Internet capabilities.

17. Describe security systems and protocols in place to protect confidential patient records.

Is the site VIPPS certified and licensed in every state?

18. Please provide the following information regarding the proposed account team:

Name of Team Member

Years of PBM Experience

Number of Assigned Accounts Location

Strategic Account Executive Account Manager Implementation Manager Clinical Pharmacists

19. Please provide the PBM’s Book-of-Business Turnover Rate for the following divisions:

CY 2017 Overall Book-of-Business Strategic Account Executives Account Managers Client-Facing Clinical Pharmacists


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REPORTING, IT & DATA INTEGRATION C.


REPORTING, IT & DATA INTEGRATION VENDOR RESPONSE

1. Indicate for each report noted below whether you can provide such a report. If you can provide the requested report, indicate the price or if the cost is included in the basic fee. Yes/No Cost Frequency

a. Eligibility Report which shows accuracy of updates and changes

b. Paid Claims Summary (Ingredient cost, days supply, dispensing fees, taxes, copay totals by month)

c. Detail Claim Listing (Utilization and Ingredient cost by individual claimant, listing the Drug name and dosage, submitted charge, allowable charge, paid)

d. Cost Sharing Report (Amounts determined to be ineligible, amounts applied to copays and coinsurance, and amounts adjusted for COB)

e. Detailed Utilization Report (# of prescriptions submitted by single source brand, multi-source brand and generic drugs, including average AWP, Ingredient cost per Rx, Dispensing fee, and average days supply)

f. Top Drug Report (detail of cost and utilization by top drug products)

g. High Amount Claimant report

h. Therapeutic Interchange Report detailing success rates and cost impacts of PBM initiated interchanges

i. Drug Utilization Review activity and Savings Report by type of edit

j. Member compliance and adherence to therapy

k. Formulary Savings and Rebate report

l. Paid Claims Summary (see b.) showing total number of claims, eligible charges and claim payments for each category

m. Prior Authorization and other clinical program reporting

n. Specialty Rx reporting

o. Pharmacy cost and utilization reporting

2. Currently the State’s Rx data is transferred twice a month from the PBM to the medical administrator. Please confirm you are able to continue this practice.

3. Do you agree to provide at no cost to the State annual member electronic EOB statements?


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FORMULARY MANAGEMENT & REBATES D.

Confirm you agree to the following formulary management and rebate(s) specifications:

FORMULARY MANAGEMENT & REBATES VENDOR CONFIRMATION

1. Confirm that you will pass through 100% of formulary rebates from manufacturers of generic drugs in addition to brand and specialty drugs.

2. Confirm that you indicated, in the financial section of this RFP, if you require a formulary management fee and the amount or percentage proposed. Other than these fees, confirm that you guarantee that 100% of all rebates collected will be passed through to the State.

3. Confirm that you guarantee that any formulary switches which are not economically advantageous to the State on an ingredient cost basis will be reported and reimbursed to the State on a dollar-for-dollar basis using the least expensive, therapeutically equivalent alternative drug as the basis for reimbursement.


FORMULARY MANAGEMENT & REBATES VENDOR RESPONSE

1. Provide the name of the Formulary you are proposing to the State.

If applicable, provide the number of drug exclusions as well as a list of the excluded drugs and the therapeutic alternatives

2. Does the PBM use an external organization for rebate aggregation? If so, which one?

3. Confirm a member is able to obtain an excluded prescription through a Prior Authorization without impact to the guaranteed rebates

4. Are any P&T committee members employed by or under contract with any drug manufacturers?

Are any P&T members directly employed by your organization?

5. Are any generic drugs considered “non-preferred” on your proposed formulary (i.e., subject to the “non-preferred” copay)? If yes, please describe in detail and provide examples. (If no, then your response to question #9 below should be 100% for generics at both retail and mail. Please confirm.)

6. Do you have a Formulary Grievance Process in place to address member concerns regarding formulary alternatives?

If yes, explain this process in detail.


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7. For the State’s top 100 retail brand prescriptions by cost during November 1, 2016 through October 31, 2017 for both the commercial and EGWP populations, please complete the Excel spreadsheets provided in Appendix C indicating whether each brand drug will be considered “preferred” or “non-preferred.”8

8. For the State’s top 100 mail brand prescriptions by cost during November 1, 2016 through October 31, 2017 for both the commercial and EGWP populations, please complete the Excel spreadsheets provided in Appendix C indicating whether each brand drug will be considered “preferred” or “non-preferred.”8

The two (2) electronic copies of your RFP response shall include responses to questions #7 and #8 in the MS Excel format provided. DO NOT PDF your response.

9. Based on the State’s detailed claim-by-claim prescription drug data during November 1, 2016 through October 31, 2017 for both the commercial and EGWP populations (Appendix B), please indicate what percent of retail and mail generic and brand prescriptions are currently considered “preferred” on your proposed formulary:

Commercial

Retail Mail

Preferred Generics as a Percent of all Generics: % %

Preferred Brands as a Percent of all Brands: % %

EGWP

Retail Mail

Preferred Generics as a Percent of all Generics: % %

Preferred Brands as a Percent of all Brands: % %

8 Please make sure that you answer "Yes" for only those situations where the exact drug listed is considered

“preferred.” For example, if Flonase is listed and is not considered “preferred” on your proposed formulary, then you should answer "No", even though the generic equivalent may be considered “preferred” (i.e., you should only answer "Yes" if the brand Flonase is considered “preferred”).


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DRUG UTILIZATION REVIEW E.

Confirm you agree to the following drug utilization review specification:

DRUG UTILIZATION REVIEW VENDOR CONFIRMATION

1. Confirm that reported savings from drug utilization review will be based on a State-specific claim-by-claim analysis.


DRUG UTILIZATION REVIEW VENDOR RESPONSE

1. It is expected that all pharmacies will have real-time online edits. If this is not the case, indicate the variation. Complete the following table separately for pharmacy network and mail order:

Real Time Edit Criterion (yes/no)

% of Pharmacies that Satisfy Criterion

% of Pharmacies

with real time,

Online edits

Percent of Total Rxs Denied (In CY 2017)

Eligible Employee/Dependent

Eligible Drug

Contract Price of Drug

Drug Interactions

Duplicate Prescription

Refill too Soon

Proper Dosage

Proper Days Supply

Generic Availability

Patient Copayments

Other (List)

2. Provide most recent quarterly book of business savings for the following programs:

a. Concurrent DUR _______% of Total Ingredient Costs

b. Retrospective DUR _______% of Total Ingredient Costs

c. Prior Authorization _______% of Total Ingredient Costs

3. Do you have edits or programs in place designed to detect and address potential drug fraud, waste, and/or abuse?

If yes, explain and include a listing of the specific drugs targeted by these programs.

4. What criteria and methodologies are used to identify and monitor high cost claimants?


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DRUG UTILIZATION REVIEW VENDOR RESPONSE

5. How do you guard against the filling of separate prescriptions for the same or similar drugs at different pharmacies on the same day?

Within five days after the initial fill?

6. Will you reimburse the State for any amounts paid for any day supply dispensed for each claimant beyond the indicated amount? [During instances of lost or stolen Rxs, the State and patient will be responsible for their respective cost shares.]

7. Identify which of the following edits are performed at the point-of-sale: Performed at the Point of Sale (Yes or No)

Ineligible participant

Pre-existing condition

Coordination of Benefits (COB)

Benefit maximums for certain drug types

Drug is inappropriate for the patient due to age

Drug is inappropriate for the patient due to gender

Quantity versus Time

Allergy

Incorrect AWP or formula price

Usual Customary Reasonable (UCR) input

Duplicate Rx

Refill too soon

Incorrect dosage

Rx splitting

Drug interactions

Over utilization

Under utilization

Aggregate Benefit Maximums

Possible Narcotic Abuse

Other Point of Sale (POS) Edits (provide list)


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NETWORK MANAGEMENT & QUALITY ASSESSMENT F.

Confirm you agree to the following network management and quality assessment specifications:

NETWORK MANAGEMENT & QUALITY ASSESSMENT VENDOR CONFIRMATION

1. Confirm that safeguards exist for preventing one group's experience from being charged to another.

2. Confirm that you guarantee that the State will be charged the generic price and the member charged the generic copay if a generic is out of stock.

3. Confirm that your organization will comply with all HIPAA regulations and that you provide, upon request, supporting documentation outlining your organizations HIPAA policies and procedures as they relate to management of the prescription benefit plan for the State.

4. Confirm that the State has the ability to pend payments to pharmacies currently identified by the State and reported to PBM as engaging in suspicious dispensing practices.

5. Confirm that you will set a maximum reimbursement dollar limit on all compounded claims and notify the State when the limit is exceeded.

6. Confirm that the State will receive a 90-day notice, when possible, of any event or negotiation that may cause a disruption in the retail pharmacy network access.


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MAIL ORDER G.

Confirm you agree to the following mail order specifications:

MAIL ORDER VENDOR CONFIRMATION

1. Confirm that you will set the threshold for the uncollected member cost share at mail at $100.

2. Confirm that you will be responsible for collection of member cost share and will be at risk for uncollected monies.


MAIL ORDER VENDOR RESPONSE

1. Complete the following for your proposed mail order facility for the State:

a. Mail-order facility location

b. Days of Operation

c. Hours of Operation

2. Complete the following for your proposed mail order facility for the State for CY 2017

a. Total Scripts Filled

b. Utilization as Percent of Capacity

c. Average Turnaround with No Intervention Required

d. Average Turnaround Intervention Required

3. Complete the following for your proposed mail order facility for the State:

a. Number of full-time Clinicians/ Pharmacists on staff at facility

b. Number of part-time Clinicians/ Pharmacists on staff at facility

c. Number of Registered Pharmacists d. Number of Pharmacy Technicians e. Number of Other clinical staff (specify) f. Which organizations are used for delivery

services?

4. Does your mail order facility have auto refill?

If so, please confirm members will have the ability to turn auto refill ON and OFF via the website and via phone.


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SPECIALTY PHARMACY PROGRAM H.

Confirm you agree to the following specialty pharmacy program specification:

SPECIALTY PHARMACY PROGRAM VENDOR CONFIRMATION

1. Confirm that members will not incur any additional costs for the delivery of specialty drugs.

2. Confirm the PBM agrees to notify the State and its members at least 60 days prior to the addition of a drug to specialty drug list and at least 90 days prior to a deletion of a drug from the specialty drug list.

3. Confirm the State reserves the right to approve any addition to the specialty drug list.


SPECIALTY PHARMACY PROGRAM VENDOR RESPONSE

1. Can your organization implement a separate plan design for specialty drugs?

2. Are your proposed guarantees for your retail/mail program contingent upon the State's purchase of your specialty drug program?

3. Based on the State’s prescription drug claims experience for November 1, 2016 through October 31, 2017

(Appendix B), indicate (in the table below) the percent retail and mail prescriptions/AWP that will be considered Specialty Drugs under your proposal and covered under your proposed specialty financial terms in Section V.

Commercial EGWP

Specialty Rx’s at Retail as a Percent of all Retail Rx’s % %

Specialty AWP at Retail as a Percent of all Retail AWP % %

Specialty Rx’s at Mail as a Percent of all Mail Rx’s % %

Specialty AWP at Mail as a Percent of all Mail AWP % %

1. Based on the State’s prescription drug claims experience for November 1, 2016 through October 31, 2017 (Appendix B) for prescriptions that were dispensed at retail, and are considered Specialty Drugs under your proposal and your specialty drug program pricing list provided in response to question 2 included under “Specialty Pharmacy Program Pricing” in Section V, what is the weighted average AWP discount for these Specialty Drugs at retail? Provide the weighted average separately for the commercial and EGWP populations.

Based on the State’s prescription drug claims experience for November 1, 2016 through October 31, 2017 (Appendix B) for prescriptions that were dispensed at mail, and are considered Specialty Drugs under your proposal and your specialty drug program pricing list provided in response to question 2 included under “Specialty Pharmacy Program Pricing” in Section V, what is the weighted average AWP discount for these Specialty Drugs at mail? Provide the weighted average separately for the commercial and EGWP populations.


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MEDICARE PART D EGWP PROGRAM I.

Confirm you agree to the following Medicare Part D EGWP program specifications:

MEDICARE PART D EGWP PROGRAM VENDOR CONFIRMATION

1. Confirm that you provided your per-Part D eligible member-per-month administrative fee for EGWP in your response to the Financial Section of this RFP.

2. Confirm that your administrative fee includes all CMS required member communications.

3. Confirm that you and your EGWP product meet all CMS requirements.

4. Confirm that, for each Medicare-eligible Retiree who is age 65 and older, plus any known Medicare-eligible dependents of theirs, who received benefits for Medicare Part D “Covered Drugs”, during the requested data period, you provide aggregate prescription drug data for each individual that contains the following elements (only for claims that are Medicare Part D covered drugs), in an Excel format, to include:

a. Unique de-identifiable claimant ID number

b. A unique de-identifiable member ID number

c. Claimant coverage status (disabled active, retired, dependent of retiree)

d. Claimant date of birth

e. Total claims paid by the State

f. Total drug costs (including dispensing fees and sales tax, but not including admin fees.)

g. Total claims paid by the claimant

h. Total rebates – If rebates cannot be provided by each individual claimant, rebate information in aggregate for Medicare retirees or total rebates for the State if not separated by eligibility is expected.


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MEDICARE PART D EGWP VENDOR RESPONSE

1. Describe how you ensure adequate reporting to the State of the manufacturer rebates retained by the PBM in lieu of administrative fees.

2. How do you propose to submit claims information for drugs that may be payable under either Medicare Part B or D?

3. Do you use the CMS simplified methodology, which allows a plan sponsor to reduce costs by 0.3 percent rather than identifying drugs that could be payable under Part B or D?

If not, what other method is used?*

4. If an individual has prescription drug coverage under the State’s Rx plan and also enrolls in another Medicare Part D prescription drug plan, how do you identify such a situation at the point of sale?

5. Do you perform the coordination of benefits at the point of sale or do paper claims have to be submitted?*

a. At the point of sale

b. Paper claims have to be submitted

6. A PBM (or other administrator) must contractually acknowledge that the information it will provide to the State will be used by the State for the purpose of obtaining federal funds. Provide a copy of your certification language.

a. Attached

b. Not attached

7. Please indicate whether your firm is currently a CMS approved Medicare Part D prescription drug plan that can contract with plan sponsors to establish and manage EGWPs.

8. Please indicate whether any EGWP functions are sub-contracted to other organizations. If so, please describe.

9. Provide a description of your MTM program

* Question is asked for informational purposes and to assist in the evaluation of the proposal and the scoring of other

questions. This question will not be scored directly.


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MEDICARE PART D EGWP VENDOR RESPONSE including the processes for enrollment, targeting, intervention, and outcomes reporting.

10. Provide your book-of-business prescription drug event (PDE) error rate for 2016 and 2017.

11. Describe the transition process you will utilize for members who are currently using non-formulary prescription drugs, drugs requiring prior authorization, step therapy, and quantity level limits.

12. Describe the enrollment/disenrollment process and include detail regarding the timing of when enrollment/disenrollment changes go into effect.

State of New Hampshire SECTION X

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SECTION IX: NETWORK DISRUPTION


1. Confirm that your proposal is based on your broadest network.

2. What is the current number of retail pharmacies in your network?

3. List any pharmacy chain with over 50 stores that are excluded from your quoted network.

4. Based on all the State’s retail prescriptions during November 1, 2016 through October 31, 2017 (Appendix B), please prepare a “disruption” analysis and complete the following tables for both the commercial and EGWP populations. As indicated, provide the requested information for all pharmacies located within the State of New Hampshire and all pharmacies located outside of New Hampshire.

Commercial*

Retail Pharmacies Located in the State of NH

NOT in the State of NH

All Retail Pharmacies

Total retail pharmacies in claims data:

Total count of these retail pharmacies in your network:

Total retail prescriptions in claims data:

Total retail prescriptions in your network:

EGWP*

Retail Pharmacies Located in the State of NH

NOT in the State of NH

All Retail Pharmacies

Total retail pharmacies in claims data:

Total count of these retail pharmacies in your network:

Total retail prescriptions in claims data:

Total retail prescriptions in your network:

* Your disruption analysis should only include positive retail prescriptions. These claims are indicated:

(1) with an “R” in the “MailRetailInd” field; and

(2) by a positive “1” in the “ClaimCounter” field.

State of New Hampshire SECTION X

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SECTION X: CLIENT REFERENCES

Provide the name of your five (5) largest public sector (states, municipalities, etc.) clients for which you provide comparable services as requested in this RFP. For these five clients, provide: • Key contact’s name, including phone number and email address • Address • Number of active members (i.e., employees and dependents) • Number of non-Medicare retiree members • Number of Medicare retiree members • A summary of the services provided by the Vendor to the client The State reserves the right to contact any or all of these clients for references and consider the references’ experiences with the vendor in the Client References score. Additionally, the State also reserves the right to use itself as a reference and consider its own experiences with the vendor in the Client References score.

State of New Hampshire APPENDICES

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APPENDICES: GROUP INFORMATION

APPENDIX A REQUESTED PLAN DESIGNS APPENDIX B DETAILED CLAIMS EXPERIENCE APPENDIX C MONTHLY ENROLLMENT AND TOP 100 BRAND DRUGS APPENDIX D PLAN DEVIATIONS FORM APPENDIX E STATE OF NH TRANSMITTAL LETTER APPENDIX F P-37 FORM CONTRACT APPENDIX G BUSINESS ASSOCIATE AGREEMENT APPENDIX H DATA REQUEST FORM

State of New Hampshire APPENDIX A

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APPENDIX A REQUESTED PLAN DESIGNS, SERVICES & PROGRAMS

Please see plan design information in the following files attached to this RFP:

• Active Plan Summary of Benefits are provided for the current plan designs effective since November 1, 2011. Currently, all the active groups have the same plan design.

o SONH Rx - Active Summary.pdf o SONH Rx - Active Booklet.pdf

• Non-Medicare Retiree Plan Summary of Benefits are provided for the current plan designs effective since January 1, 2016.

o SONH Rx - Non-Medicare Retiree Summary.pdf

o SONH Rx - Non-Medicare Retiree Booklet.pdf

• Active and Non-Medicare Retiree Plans – Additional Information

o Mail Order Opt Out Program.pdf

o Express_Scripts_National_Preferred_Formulary_List.pdf

o Express_Scripts_Preferred_Drug_List_Exclusions.pdf

• Medicare Retiree Plan Summary of Benefits are provided for the current plan designs effective since January 1, 2016.

o SONH Rx - EGWP Benefit Overview.pdf o SONH Rx - EGWP Evidence of Coverage Booklet.pdf

HISTORIC PLAN CHANGES

• Active Plan – No plan design changes in the past 5 years.

• Medicare Retiree Plan – Effective January 1, 2015, transitioned to an EGWP.

• Retiree Plans (Non-Medicare and Medicare) – Effective January 1, 2016, the below copayment and maximum out-of-pocket changes were implemented for all retirees.

Prior to January 1, 2016

Effective January 1, 2016

Retail Pharmacy (31-day supply)

Generic Copayment $10 $10

Preferred Brand Copayment $20 $25

Non-Preferred Brand Copayment $35 $40

Mail Order Pharmacy (90-day supply)

Generic Copayment $1 $10

Preferred Brand Copayment $40 $50

Non-Preferred Brand Copayment $70 $80

Annual Maximum Out-of-Pocket (retail and mail order combined)

$500 individual / $1,000 family

$750 individual / $1,500 family

State of New Hampshire APPENDIX B

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APPENDIX B INFORMATION BELOW NEEDS TO BE REQUESTED

Please see Appendix H: Data Request form and contact Danielle Bishop at [email protected] to request this information. Access to this data on the State’s FTP site shall be provided to prospective Vendors who manifest a reasonable likelihood of meeting the minimum qualifications of this RFP. Such likelihood shall be evidenced by the apparent provider network of the prospective Vendor. DETAILED CLAIMS EXPERIENCE FOR REPRICING

• Text files for both the Commercial and EGWP populations containing the State’s detailed prescription drug claims experience for each prescription dispensed is available upon request. These files contain the following information for all prescriptions dispensed from November 1, 2016 through October 31, 2017.

Plan Option*

National Drug Code (NDC)

Prescription Fill Date

Prescription Fill. Number

Days Supply Dispensed

Metric Units Dispensed

Formulary Indicator

Retail / Mail Indicator

DAW Code

Claim Status

Pharmacy NABP Number

Patient Relationship

* The “PlanGroupHierarchy_2” field identifies the Plan Option. The Retiree Plan prescriptions in the Commercial population file have the field values listed in the chart below. (All other field values indicate Active Plan prescriptions.)

Retiree Plan RETU65POS RETU65PPO RETO65MED LEGO65RET


State of New Hampshire APPENDIX C

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APPENDIX C

INFORMATION BELOW NEEDS TO BE REQUESTED

Please see Appendix H: Data Request form. Contact Danielle Bishop at [email protected] to request this information. Access to this data on the State’s FTP site shall be provided to prospective Vendors who manifest a reasonable likelihood of meeting the minimum qualifications of this RFP. Such likelihood shall be evidenced by the apparent provider network of the prospective Vendor. MONTHLY ENROLLMENT AND TOP 100 BRAND DRUGS

• Monthly enrollment counts from October 2016 to October 2017(tab #1)

• State’s Commercial top 100 retail brand prescriptions by cost 11/1/2016 – 10/31/2017 (tab #2)

• State’s Commercial top 100 mail brand prescriptions by cost 11/1/2016 – 10/31/2017 (tab #3)

• State’s EGWP top 100 retail brand prescriptions by cost 11/1/2016 – 10/31/2017 (tab #4)

• State’s EGWP top 100 mail brand prescriptions by cost 11/1/2016 – 10/31/2017 (tab #5)


State of New Hampshire APPENDIX D

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APPENDIX D

PLAN DEVIATIONS FORM This form needs to be completed and returned with your proposal in order to be considered in the carrier selection process. Active Plan Design

[ ] This is to certify that the submitted proposal includes no deviations to the Active Plan design as outlined in the benefit summaries.

Non-Medicare Retiree Plan Design

[ ] This is to certify that the submitted proposal includes no deviations to the Non-Medicare Retiree Plan design as outlined in the benefit summaries.

Medicare (EGWP) Retiree Plan Design

[ ] This is to certify that the submitted proposal includes no deviations to the Medicare Retiree Plan design as outlined in the benefit summaries.

All Other Requirements outlined in the RFP Important: Note that any deviations determined to be material may result in the rejection of the bid.

[ ] This is to certify that the submitted proposal adheres to all the requirements outlined in the RFP with the following exceptions:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

[ ] This is to certify that the submitted proposal adheres to all the requirements outlined in the RFP with no deviations.

____________________________________ Signature ____________________________________ Print Name ____________________________________

Title

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APPENDIX E STATE OF NEW HAMPSHIRE REQUEST FOR PROPOSAL TRANSMITTAL LETTER

Date: ___________________ Company Name: ________________________________________

Address: _________________________________________________________ _________________________________________________________

To: Point of Contact: Danielle Bishop Telephone: 603-271-3290 RE: Proposal Invitation Name: Pharmacy Benefit Management Services RFP Number: 2018-203 RFP Posted Date (on or by): December 8, 2017 RFP Opening Date and Time: January 19, 2018 at 2:00 PM (ET) [Insert name of signor]_____________________________, on behalf of _____________________________ [insert name of entity submitting RFP(collectively referred to as “Vendor”) hereby submits an offer as contained in the written RFPRFP submitted herewith (“RFP”) to the State of New Hampshire in response to RFP # 2017-192 for Administration of Medical Benefit services at the price(s) quoted herein in complete accordance with the RFP. Vendor attests to the fact that: 1. The Vendor has reviewed and agreed to be bound by all RFP terms and conditions. 2. The Vendor has not altered any of the language or other provisions contained in the RFP document. 3. The RFP is effective for a minimum period of 6 months from the RFP Opening date as indicated above. 4. The prices Vendor has quoted in the proposal were established without collusion with other vendors. 5. The Vendor has read and fully understands this RFP. 6. Further, in accordance with RSA 21-I:11-c, the undersigned Vendor certifies that neither the Vendor nor any of its subsidiaries, affiliates or principal officers (principal officers refers to individuals with management responsibility for the entity or association):

a. Has, within the past 2 years, been convicted of, or pleaded guilty to, a violation of RSA 356:2, RSA 356:4, or any state or federal law or county or municipal ordinance prohibiting specified bidding practices, or involving antitrust violations, which has not been annulled;

b. Has been prohibited, either permanently or temporarily, from participating in any public works project pursuant to RSA 638:20; c. Has previously provided false, deceptive, or fraudulent information on a vendor code number application form, or any other

document submitted to the state of New Hampshire, which information was not corrected as of the time of the filing a bid, proposal, or quotation;

d. Is currently debarred from performing work on any project of the federal government or the government of any state; e. Has, within the past 2 years, failed to cure a default on any contract with the federal government or the government of any state; f. Is presently subject to any order of the department of labor, the department of employment security, or any other state department,

agency, board, or commission, finding that the applicant is not in compliance with the requirements of the laws or rules that the department, agency, board, or commission is charged with implementing;

g. Is presently subject to any sanction or penalty finally issued by the department of labor, the department of employment security, or any other state department, agency, board, or commission, which sanction or penalty has not been fully discharged or fulfilled;

h. Is currently serving a sentence or is subject to a continuing or unfulfilled penalty for any crime or violation noted in this section; i. Has failed or neglected to advise the division of any conviction, plea of guilty, or finding relative to any crime or violation noted in this

section, or of any debarment, within 30 days of such conviction, plea, finding, or debarment; or j. Has been placed on the debarred parties list described in RSA 21-I:11-c within the past year.

Authorized Signor’s Signature _______________________________ Authorized Signor’s Title ________________________

NOTARY PUBLIC/JUSTICE OF THE PEACE COUNTY: ___________________________ STATE: ______________ ZIP: _________________ On the _____ day of _______________, 2017, personally appeared before me, the above named ________________________, in his/her capacity as authorized representative of ________________, known to me or satisfactorily proven, and took oath that the foregoing is true and accurate to the best of his/her knowledge and belief. In witness thereof, I hereunto set my hand and official seal. _________________________________________________________ (Notary Public/Justice of the Peace) My commission expires: _________________________________________________________ (Date)

Form P37-A

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Notice: This agreement and all of its attachments shall become public upon submission to Governor and Executive Council for approval. Any information that is private, confidential or proprietary must be clearly identified to the agency and agreed to in writing prior to signing the contract.

APPENDIX F

Subject: SAMPLE FORM - TO BE COMPLETED BY SELECTED VENDOR

FORM NUMBER P-37 (version 5/8/15)

AGREEMENT

The State of New Hampshire and the Contractor hereby mutually agree as follows:

GENERAL PROVISIONS

1. IDENTIFICATION. 1.1 State Agency Name

1.2 State Agency Address

1.3 Contractor Name

1.4 Contractor Address

1.5 Contractor Phone Number

1.6 Account Number

1.7 Completion Date

1.8 Price Limitation

1.9 Contracting Officer for State Agency

1.10 State Agency Telephone Number

1.11 Contractor Signature

1.12 Name and Title of Contractor Signatory

1.13 Acknowledgement: State of , County of On , before the undersigned officer, personally appeared the person identified in block 1.12, or satisfactorily proven to be the person whose name is signed in block 1.11, and acknowledged that s/he executed this document in the capacity indicated in block 1.12. 1.13.1 Signature of Notary Public or Justice of the Peace [Seal] 1.13.2 Name and Title of Notary or Justice of the Peace 1.14 State Agency Signature

Date:

1.15 Name and Title of State Agency Signatory

1.16 Approval by the N.H. Department of Administration, Division of Personnel (if applicable) By: Director, On:

1.17 Approval by the Attorney General (Form, Substance and Execution) (if applicable) By: On: 1.18 Approval by the Governor and Executive Council By: On:

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2. EMPLOYMENT OF CONTRACTOR/SERVICES TO BE PERFORMED. The State of New Hampshire, acting through the agency identified in block 1.1 (“State”), engages contractor identified in block 1.3 (“Contractor”) to perform, and the Contractor shall perform, the work or sale of goods, or both, identified and more particularly described in the attached EXHIBIT A which is incorporated herein by reference (“Services”). 3. EFFECTIVE DATE/COMPLETION OF SERVICES. 3.1 Notwithstanding any provision of this Agreement to the contrary, and subject to the approval of the Governor and Executive Council of the State of New Hampshire, if applicable, this Agreement, and all obligations of the parties hereunder, shall become effective on the date the Governor and Executive Council approve this Agreement as indicated in block 1.18, unless no such approval is required, in which case the Agreement shall become effective on the date the Agreement is signed by the State Agency as shown in block 1.14 (“Effective Date”). 3.2 If the Contractor commences the Services prior to the Effective Date, all Services performed by the Contractor prior to the Effective Date shall be performed at the sole risk of the Contractor, and in the event that this Agreement does not become effective, the State shall have no liability to the Contractor, including without limitation, any obligation to pay the Contractor for any costs incurred or Services performed. Contractor must complete all Services by the Completion Date specified in block 1.7. 4. CONDITIONAL NATURE OF AGREEMENT. Notwithstanding any provision of this Agreement to the contrary, all obligations of the State hereunder, including, without limitation, the continuance of payments hereunder, are contingent upon the availability and continued appropriation of funds, and in no event shall the State be liable for any payments hereunder in excess of such available appropriated funds. In the event of a reduction or termination of appropriated funds, the State shall have the right to withhold payment until such funds become available, if ever, and shall have the right to terminate this Agreement immediately upon giving the Contractor notice of such termination. The State shall not be required to transfer funds from any other account to the Account

identified in block 1.6 in the event funds in that Account are reduced or unavailable. 5. CONTRACT PRICE/PRICE LIMITATION/ PAYMENT. 5.1 The contract price, method of payment, and terms of payment are identified and more particularly described in EXHIBIT B which is incorporated herein by reference. 5.2 The payment by the State of the contract price shall be the only and the complete reimbursement to the Contractor for all expenses, of whatever nature incurred by the Contractor in the performance hereof, and shall be the only and the complete compensation to the Contractor for the Services. The State shall have no liability to the Contractor other than the contract price. 5.3 The State reserves the right to offset from any amounts otherwise payable to the Contractor under this Agreement those liquidated amounts required or permitted by N.H. RSA 80:7 through RSA 80:7-c or any other provision of law. 5.4 Notwithstanding any provision in this Agreement to the contrary, and notwithstanding unexpected circumstances, in no event shall the total of all payments authorized, or actually made hereunder, exceed the Price Limitation set forth in block 1.8. 6. COMPLIANCE BY CONTRACTOR WITH LAWS AND REGULATIONS/ EQUAL EMPLOYMENT OPPORTUNITY. 6.1 In connection with the performance of the Services, the Contractor shall comply with all statutes, laws, regulations, and orders of federal, state, county or municipal authorities which impose any obligation or duty upon the Contractor, including, but not limited to, civil rights and equal opportunity laws. This may include the requirement to utilize auxiliary aids and services to ensure that persons with communication disabilities, including vision, hearing and speech, can communicate with, receive information from, and convey information to the Contractor. In addition, the Contractor shall comply with all applicable copyright laws. 6.2 During the term of this Agreement, the Contractor shall not discriminate against employees or applicants for employment because of race, color, religion, creed, age, sex, handicap, sexual orientation, or national origin and will take affirmative action to prevent such discrimination.

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6.3 If this Agreement is funded in any part by monies of the United States, the Contractor shall comply with all the provisions of Executive Order No. 11246 (“Equal Employment Opportunity”), as supplemented by the regulations of the United States Department of Labor (41 C.F.R. Part 60), and with any rules, regulations and guidelines as the State of New Hampshire or the United States issue to implement these regulations. The Contractor further agrees to permit the State or United States access to any of the Contractor’s books, records and accounts for the purpose of ascertaining compliance with all rules, regulations and orders, and the covenants, terms and conditions of this Agreement. 7. PERSONNEL. 7.1 The Contractor shall at its own expense provide all personnel necessary to perform the Services. The Contractor warrants that all personnel engaged in the Services shall be qualified to perform the Services, and shall be properly licensed and otherwise authorized to do so under all applicable laws. 7.2 Unless otherwise authorized in writing, during the term of this Agreement, and for a period of six (6) months after the Completion Date in block 1.7, the Contractor shall not hire, and shall not permit any subcontractor or other person, firm or corporation with whom it is engaged in a combined effort to perform the Services to hire, any person who is a State employee or official, who is materially involved in the procurement, administration or performance of this Agreement. This provision shall survive termination of this Agreement. 7.3 The Contracting Officer specified in block 1.9, or his or her successor, shall be the State’s representative. In the event of any dispute concerning the interpretation of this Agreement, the Contracting Officer’s decision shall be final for the State. 8. EVENT OF DEFAULT/REMEDIES. 8.1 Any one or more of the following acts or omissions of the Contractor shall constitute an event of default hereunder (“Event of Default”): 8.1.1 failure to perform the Services satisfactorily or on schedule; 8.1.2 failure to submit any report required hereunder; and/or 8.1.3 failure to perform any other covenant, term or condition of this Agreement.

8.2 Upon the occurrence of any Event of Default, the State may take any one, or more, or all, of the following actions: 8.2.1 give the Contractor a written notice specifying the Event of Default and requiring it to be remedied within, in the absence of a greater or lesser specification of time, thirty (30) days from the date of the notice; and if the Event of Default is not timely remedied, terminate this Agreement, effective two (2) days after giving the Contractor notice of termination; 8.2.2 give the Contractor a written notice specifying the Event of Default and suspending all payments to be made under this Agreement and ordering that the portion of the contract price which would otherwise accrue to the Contractor during the period from the date of such notice until such time as the State determines that the Contractor has cured the Event of Default shall never be paid to the Contractor; 8.2.3 set off against any other obligations the State may owe to the Contractor any damages the State suffers by reason of any Event of Default; and/or 8.2.4 treat the Agreement as breached and pursue any of its remedies at law or in equity, or both. 9. DATA/ACCESS/CONFIDENTIALITY/ PRESERVATION. 9.1 As used in this Agreement, the word “data” shall mean all information and things developed or obtained during the performance of, or acquired or developed by reason of, this Agreement, including, but not limited to, all studies, reports, files, formulae, surveys, maps, charts, sound recordings, video recordings, pictorial reproductions, drawings, analyses, graphic representations, computer programs, computer printouts, notes, letters, memoranda, papers, and documents, all whether finished or unfinished. 9.2 All data and any property which has been received from the State or purchased with funds provided for that purpose under this Agreement, shall be the property of the State, and shall be returned to the State upon demand or upon termination of this Agreement for any reason. 9.3 Confidentiality of data shall be governed by N.H. RSA chapter 91-A or other existing law. Disclosure of data requires prior written approval of the State.

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10. TERMINATION. In the event of an early termination of this Agreement for any reason other than the completion of the Services, the Contractor shall deliver to the Contracting Officer, not later than fifteen (15) days after the date of termination, a report (“Termination Report”) describing in detail all Services performed, and the contract price earned, to and including the date of termination. The form, subject matter, content, and number of copies of the Termination Report shall be identical to those of any Final Report described in the attached EXHIBIT A. 11. CONTRACTOR’S RELATION TO THE STATE. In the performance of this Agreement the Contractor is in all respects an independent contractor, and is neither an agent nor an employee of the State. Neither the Contractor nor any of its officers, employees, agents or members shall have authority to bind the State or receive any benefits, workers’ compensation or other emoluments provided by the State to its employees. 12. ASSIGNMENT/DELEGATION/SUBCONTRACTS. The Contractor shall not assign, or otherwise transfer any interest in this Agreement without the prior written notice and consent of the State. None of the Services shall be subcontracted by the Contractor without the prior written notice and consent of the State. 13. INDEMNIFICATION. The Contractor shall defend, indemnify and hold harmless the State, its officers and employees, from and against any and all losses suffered by the State, its officers and employees, and any and all claims, liabilities or penalties asserted against the State, its officers and employees, by or on behalf of any person, on account of, based or resulting from, arising out of (or which may be claimed to arise out of) the acts or omissions of the Contractor. Notwithstanding the foregoing, nothing herein contained shall be deemed to constitute a waiver of the sovereign immunity of the State, which immunity is hereby reserved to the State. This covenant in paragraph 13 shall survive the termination of this Agreement. 14. INSURANCE. 14.1 The Contractor shall, at its sole expense, obtain and maintain in force, and shall require any subcontractor or assignee to obtain and maintain in force, the following insurance:

14.1.1 comprehensive general liability insurance against all claims of bodily injury, death or property damage, in amounts of not less than $1,000,000per occurrence and $2,000,000 aggregate ; and 14.1.2 special cause of loss coverage form covering all property subject to subparagraph 9.2 herein, in an amount not less than 80% of the whole replacement value of the property. 14.2 The policies described in subparagraph 14.1 herein shall be on policy forms and endorsements approved for use in the State of New Hampshire by the N.H. Department of Insurance, and issued by insurers licensed in the State of New Hampshire. 14.3 The Contractor shall furnish to the Contracting Officer identified in block 1.9, or his or her successor, a certificate(s) of insurance for all insurance required under this Agreement. Contractor shall also furnish to the Contracting Officer identified in block 1.9, or his or her successor, certificate(s) of insurance for all renewal(s) of insurance required under this Agreement no later than thirty (30) days prior to the expiration date of each of the insurance policies. The certificate(s) of insurance and any renewals thereof shall be attached and are incorporated herein by reference. Each certificate(s) of insurance shall contain a clause requiring the insurer to provide the Contracting Officer identified in block 1.9, or his or her successor, no less than thirty (30) days prior written notice of cancellation or modification of the policy. 15. WORKERS’ COMPENSATION. 15.1 By signing this agreement, the Contractor agrees, certifies and warrants that the Contractor is in compliance with or exempt from, the requirements of N.H. RSA chapter 281-A (“Workers’ Compensation”). 15.2 To the extent the Contractor is subject to the requirements of N.H. RSA chapter 281-A, Contractor shall maintain, and require any subcontractor or assignee to secure and maintain, payment of Workers’ Compensation in connection with activities which the person proposes to undertake pursuant to this Agreement. Contractor shall furnish the Contracting Officer identified in block 1.9, or his or her successor, proof of Workers’ Compensation in the manner described in N.H. RSA chapter 281-A and any applicable renewal(s) thereof, which shall be attached and are incorporated herein by reference. The State shall not be responsible for payment of

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any Workers’ Compensation premiums or for any other claim or benefit for Contractor, or any subcontractor or employee of Contractor, which might arise under applicable State of New Hampshire Workers’ Compensation laws in connection with the performance of the Services under this Agreement. 16. WAIVER OF BREACH. No failure by the State to enforce any provisions hereof after any Event of Default shall be deemed a waiver of its rights with regard to that Event of Default, or any subsequent Event of Default. No express failure to enforce any Event of Default shall be deemed a waiver of the right of the State to enforce each and all of the provisions hereof upon any further or other Event of Default on the part of the Contractor. 17. NOTICE. Any notice by a party hereto to the other party shall be deemed to have been duly delivered or given at the time of mailing by certified mail, postage prepaid, in a United States Post Office addressed to the parties at the addresses given in blocks 1.2 and 1.4, herein. 18. AMENDMENT. This Agreement may be amended, waived or discharged only by an instrument in writing signed by the parties hereto and only after approval of such amendment, waiver or discharge by the Governor and Executive Council of the State of New Hampshire unless no such approval is required under the circumstances pursuant to State law, rule or policy. 19. CONSTRUCTION OF AGREEMENT AND TERMS. This Agreement shall be construed in accordance with the laws of the State of New Hampshire, and is binding upon and inures to the benefit of the parties and their respective successors and assigns. The wording used in this Agreement is the wording chosen by the parties to express their mutual intent, and no rule of construction shall be applied against or in favor of any party. 20. THIRD PARTIES. The parties hereto do not intend to benefit any third parties and this Agreement shall not be construed to confer any such benefit. 21. HEADINGS. The headings throughout the Agreement are for reference purposes only, and the words contained therein shall in no

way be held to explain, modify, amplify or aid in the interpretation, construction or meaning of the provisions of this Agreement. 22. SPECIAL PROVISIONS. Additional provisions set forth in the attached EXHIBIT C are incorporated herein by reference. 23. SEVERABILITY. In the event any of the provisions of this Agreement are held by a court of competent jurisdiction to be contrary to any state or federal law, the remaining provisions of this Agreement will remain in full force and effect. 24. ENTIRE AGREEMENT. This Agreement, which may be executed in a number of counterparts, each of which shall be deemed an original, constitutes the entire Agreement and understanding between the parties, and supersedes all prior Agreements and understandings relating hereto.

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APPENDIX G Note: Below is the State’s current Business Associate Agreement (BAA). The Selected Vendor will be required to sign the State’s BAA when executing the contract. The Contractor identified in Section 1.3 of the General Provisions of the Agreement agrees to comply with the Health Insurance Portability and Accountability Act, Public Law 104-191 and with the Standards for Privacy and Security of Individually Identifiable Health Information, 45 CFR Parts 160 and 164 and those parts of the HITECH Act applicable to business associates. As defined herein, “Business Associate” shall generally have the same meaning as the term “business associate” at 45 CFR 160.103, and in reference to the party to this Agreement, shall mean Contractor. “Covered Entity” shall generally have the same meaning as the term “covered entity” at 45 CFR 160.103, and in reference to the party to this Agreement shall mean the State of New Hampshire Department of Administrative Services Employee and Retiree Health Benefit Program. “HIPAA Rules” shall mean the Privacy, Security, Breach Notification, and Enforcement Rules at 45 CFR Part 160 and Part 164.

BUSINESS ASSOCIATE AGREEMENT

1. Definitions

a. The following terms used in this Agreement shall have the same meaning as those terms in the HIPAA Rules: Breach, Data Aggregation, Designated Record Set, Disclosure, Health Care Operations, Individual, Minimum Necessary, Notice of Privacy Practices, Protected Health Information, Required By Law, Secretary, Security Incident, Subcontractor, Unsecured Protected Health Information, and Use.

b. All terms not otherwise defined herein shall have the same meaning as those set forth in the HIPAA Rules.

2. Privacy and Security of Protected Health Information (PHI)

a. Permitted Uses and Disclosures

i. Business Associate shall not use, disclose, maintain or transmit PHI except as reasonably necessary to provide the services set forth in this Agreement or any agreement between the parties, or as required by law.

ii. Business Associate is authorized to use PHI to de-identify the information in accordance with 45 CFR 164.514(a)-(c). Business Associate shall de-identify the PHI in a manner consistent with HIPAA Rules. Uses and disclosures of the de-identified information shall be limited to those consistent with the provisions of this Agreement.

iii. Business Associate may use PHI as necessary to perform data aggregation services, and to create Summary Health Information and/or Limited Data Sets. Contractor shall use appropriate safeguards to prevent use or disclosure of the information other than as provided for herein, shall ensure that any agents or subcontractors to whom it provides such information agree to the same restrictions and conditions that apply to Contractor, and not identify the Summary Health Information and/or Limited Data Sets or contact the individuals other than for the management, operation and administration of the Plan.

iv. Business Associate may use and disclose PHI (a) for the management, operation and administration of the Plan, (b) for the services set forth in the Agreement, which include (but are not limited to) Treatment, Payment activities, and/or Pharmacy Benefit Management as these terms are defined in this Agreement and 45 C.F.R. § 164.501, and (c) as otherwise required to perform its obligations under this Agreement, or any

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other agreement between the parties provided that such use or disclosure would not violate the HIPAA Regulations.

v. Business Associate may disclose, in conformance with the HIPAA Rules, PHI to make disclosures of De-identified Health Information, Limited Data Sets, and Summary Health Information. Contractor shall use appropriate safeguards to prevent use or disclosure of the information other than as provided for herein, ensure that any agents or subcontractors to whom it provides such information agree to the same restrictions and conditions that apply to Contractor, and not identify the De-identified Health Information., Summary Health Information and/or Limited Data Sets or contact the individuals. Business Associate may also disclose, in conformance with the HIPAA Regulations, PHI to Health Care Providers for permitted purposes including health care operations.

vi. Business Associate may use PHI for the proper management and administration of the Business Associate or to carry out the legal responsibilities of Business Associate. To the extent Business Associate discloses PHI to a third party, Business Associate must obtain, prior to making any such disclosure, (a) reasonable assurances from the third party that such PHI will be held confidentially and used or further disclosed only as required by law or for the purpose for which it was disclosed to the third party; and (b) an agreement from such third party to notify Business Associate of any breaches of the confidentiality of the PHI, to the extent it has obtained knowledge of such breach.

vii. To the extent practicable, Business Associate shall not, unless such disclosure is reasonably necessary to provide services outlined in the Agreement, disclose any PHI in response to a request for disclosure on the basis it is required by law without first notifying Covered Entity. In the event Covered Entity objects to the disclosure it shall seek the appropriate relief and the Business Associate shall refrain from disclosing the PHI until Covered Entity has exhausted all remedies.

b. Minimum Necessary. Business Associate will, in its performance of the functions, activities, services, and operations specified above, make reasonable efforts to use, to disclose, and to request only the minimum amount of PHI reasonably necessary to accomplish the intended purpose of the use, disclosure, or request, except that Business Associate will not be obligated to comply with this minimum-necessary limitation if neither Business Associate or Covered Entity is required to limit its use, disclosure, or request to the minimum necessary under the HIPAA Rules. Business Associate and Covered Entity acknowledge that the phrase “minimum necessary” shall be interpreted in accordance with the HITECH Act and the HIPAA Rules.

c. Prohibition on Unauthorized Use or Disclosure. Business Associate may not use or disclose PHI except (1) as permitted or required by this Agreement, or any other agreement between the parties, (2) as permitted in writing by Covered Entity, or (3) as authorized by the individual or (4) as Required by Law. This agreement does not authorize Business Associate to use or disclose Covered Entity’s PHI in a manner that would violate the HIPAA Rules if done by Covered Entity, except as permitted for Business Associate’s proper management and administration as described herein.

3. Information Safeguards

a. Privacy of Protected Health Information. Business Associate will develop, implement, maintain, and use appropriate administrative, technical, and physical safeguards to protect the privacy of PHI. The safeguards must reasonably protect PHI from any intentional or unintentional use or disclosure in violation of the Privacy Rule and limit incidental uses or disclosures made pursuant to a use or disclosure otherwise permitted by this Agreement. To the extent the parties agree that the Business Associate will carry out directly one or more of

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Covered Entity’s obligations under the Privacy Rule, the Business Associate will comply with the requirements of the Privacy Rule that apply to the Covered Entity in the performance of such obligations.

b. Security of Covered Entity’s Electronic Protected Health Information. Business Associate will comply with the Security Rule and will use appropriate administrative, technical and physical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of Electronic PHI that Business Associate creates, receives, maintains or transmits on Covered Entity’s behalf.

c. No Transfer of PHI Outside United States. Business Associate will not transfer PHI outside the United States without the prior written consent of the Covered Entity. In this context a “transfer” outside the United States occurs if Business Associate’s workforce members, agents, or Subcontractors physically located outside the United States are able to, store, copy or disclose PHI.

d. Subcontractors. Business Associate will require each of its Subcontractors to agree, in a written agreement with Business Associate, to comply with the provisions of the Security Rule; to appropriately safeguard PHI created, received, maintained, or transmitted on behalf of the Business Associate; and to apply the same restrictions and conditions that apply to the Business Associate with respect to such PHI.

e. Prohibition on Sale of Protected Health Information. Business Associate shall not engage in any sale (as defined in the HIPAA rules) of PHI.

f. Prohibition on Use or Disclosure of Genetic Information. Business Associate shall not use or disclose Genetic Information for underwriting purposes in violation of the HIPAA rules.

g. Penalties for Noncompliance. Business Associate acknowledges that it is subject to civil and criminal enforcement for failure to comply with the HIPAA Rules, to the extent provided with the HITECH Act and the HIPAA Rules.

4. Compliance With Electronic Transactions Rule

a. If Business Associate conducts in whole or part electronic Transactions on behalf of Covered Entity for which HHS has established standards, Business Associate will comply, and will require any Subcontractor it involves with the conduct of such Transactions to comply, with each applicable requirement of the Electronic Transactions Rule and of any operating rules adopted by HHS with respect to Transactions.

5. Individual Rights and PHI

a. Access

i. Business Associate shall respond to an individual’s request for access to his or her PHI as part of Business Associate’s normal customer service function, if the request is communicated to Business Associate directly by the individual or the individual’s personal representative. Business Associate shall respond to the request with regard to PHI that Business Associate and/or its Subcontractors maintain in a manner and time frame consistent with requirements specified in the HIPAA Privacy Regulation.

ii. In addition, Business Associate shall assist Covered Entity in responding to requests made to Covered Entity by individuals to invoke a right of access under the HIPAA Privacy Regulation. Upon receipt of written notice (including fax and email) from Covered Entity, Business Associate shall make available to Covered Entity, or at

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Covered Entity’s direction to the individual (or the individual’s personal representative), any PHI about the individual created or received for or from Covered Entity in the control of Business Associate’s and/or its Subcontractors for inspection and obtaining copies so that Covered Entity may meet its access obligations under 45 CFR 164.524, and, where applicable, the HITECH Act. Business Associate shall make such information available in an electronic format where required by the HITECH Act.

b. Amendment

i. Business Associate shall respond to an individual’s request to amend his or her PHI as part of Business Associate’s normal customer service functions, if the request is communicated to Business Associate directly by the individual or the individual’s personal representative. Business Associate shall respond to the request with respect to the PHI Business Associate and its Subcontractors maintain in a manner and time frame consistent with requirements specified in the HIPAA Privacy Regulation.

ii. In addition, Business Associate shall assist Covered Entity in responding to requests made to Covered Entity to invoke a right to amend under the HIPAA Privacy Regulation. Upon receipt of written notice (including fax and email) from Covered Entity, Business Associate shall amend any portion of the PHI created or received for or from Covered Entity in the custody or control of Business Associate and/or its Subcontractors so that Covered Entity may meet its amendment obligations under 45 CFR 164.526.

c. Disclosure Accounting

i. Business Associate shall respond to an individual’s request for an accounting of disclosures of his or her PHI as part of Business Associate’s normal customer service function, if the request is communicated to the Business Associate directly by the individual or the individual’s personal representative. Business Associate shall respond to a request with respect to the PHI Business Associate and its Subcontractors maintain in a manner and time frame consistent with requirements specified in the HIPAA Privacy Regulation.

ii. In addition, Business Associate shall assist Covered Entity in responding to requests made to Covered Entity by individuals or their personal representatives to invoke a right to an accounting of disclosures under the HIPAA Privacy Regulation by performing the following functions so that Covered Entity may meet its disclosure accounting obligation under 45 CFR 164.528:

iii. Disclosure Tracking. Business Associate shall record each disclosure that Business Associate makes of individuals’ PHI, which is not excepted from disclosure accounting under 45 CFR 164.528(a)(1).

iv. Disclosure Information. The information about each disclosure that Business Associate must record (“Disclosure Information”) is (a) the disclosure date, (b) the name and (if known) address of the person or entity to whom Business Associate made the disclosure, (c) a brief description of the PHI disclosed, and (d) a brief statement of the purpose of the disclosure or a copy of any written request for disclosure under 45 Code of Federal Regulations §164.502(a)(2)(ii) or §164.512. Disclosure Information also includes any information required to be provided by the HITECH Act.

v. Repetitive Disclosures. For repetitive disclosures of individuals’ PHI that Business Associate makes for a single purpose to the same person or entity (including to Covered Entity or Employer), Business Associate may record (a) the Disclosure Information for

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the first of these repetitive disclosures, (b) the frequency, periodicity or number of these repetitive disclosures, and (c) the date of the last of these repetitive disclosures.

vi. Exceptions from Disclosure Tracking. Business Associate will not be obligated to record Disclosure Information or otherwise account for disclosures of PHI if Covered Entity need not account for such disclosures under the HIPAA Rules.

vii. Disclosure Tracking Time Periods. Unless otherwise provided by the HITECH Act and/or any accompanying regulations, Business Associate shall have available for Covered Entity the Disclosure Information required by Section 3.j.iii.2 above for the six (6) years immediately preceding the date of Covered Entity’s request for the Disclosure Information.

d. Confidential Communications

i. Business Associate shall respond to an individual’s request for a confidential communication as part of Business Associate’s normal customer service function, if the request is communicated to Business Associate directly by the individual or the individual’s personal representative. Business Associate shall respond to the request with respect to the PHI Business Associate and its Subcontractors maintain in a manner and time frame consistent with requirements specified in the HIPAA Privacy Regulation. If an individual’s request, made to Business Associate, extends beyond information held by Business Associate or Business Associate’s Subcontractors, Business Associate shall refer individual to Covered Entity. Business Associate assumes no obligation to coordinate any request for a confidential communication of PHI maintained by other business associates of Covered Entity.

ii. In addition, Business Associate shall assist Covered Entity in responding to requests to it by individuals (or their personal representatives) to invoke a right of confidential communication under the HIPAA Privacy Regulation. Upon receipt of written notice (including fax and email) from Covered Entity, Business Associate will begin to send all communications of PHI directed to the individual to the identified alternate address so that Covered Entity may meet its access obligations under 45 CFR 164.524.

e. Restrictions

i. Business Associate shall respond to an individual’s request for a restriction as part of Business Associate’s normal customer service function, if the request is communicated to Business Associate directly by the individual (or the individual’s personal representative). Business Associate shall respond to the request with respect to the PHI Business Associate and its Subcontractors maintain in a manner and time frame consistent with requirements specified in the HIPAA Privacy Regulation.

ii. In addition, Business Associate shall promptly, upon receipt of notice from Covered Entity, restrict the use or disclosure of individuals’ PHI, provided the Business Associate has agreed to such a restriction. Covered Entity agrees that it will not commit Business Associate to any restriction on the use or disclosure of individuals’ PHI for treatment, payment or health care operations without Business Associate’s prior written approval.

6. Breach

a. Business Associate shall report to Covered Entity, in writing, any use or disclosure of PHI in violation of the Agreement promptly upon discovery of such incident, including any Security Incident involving PHI, ePHI, or Unsecured PHI as required by 45 CFR 164.410. Such report

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shall not include instances where Business Associate inadvertently misroutes PHI to a provider, as long as the disclosure is not a Breach as defined under 45 CFR §164.402. The parties acknowledge and agree that attempted but Unsuccessful Security Incidents (as defined below) that occur on a daily basis will not be reported. “Unsuccessful Security Incidents” shall include, but not be limited to, pings and other broadcast attacks on Business Associate’s firewall, port scans, unsuccessful log-on attempts, denials of service and any combination of the above, so long as no such incident results in unauthorized access, use or disclosure of PHI.

b. Business Associate shall report a Breach or a potential Breach to Covered Entity upon discovery of any such incident. Business Associate will treat a Breach or potential Breach as being discovered as of the first day on which such incident is known to Business Associate, or by exercising reasonable diligence, would have been known to Business Associate. Business Associate shall be deemed to have knowledge of a Breach or potential Breach if such incident is known, or by exercising reasonable diligence would have been known, to any person, other than the person committing the Breach, who is an employee, officer or other agent of Business Associate. If a delay is requested by a law-enforcement official in accordance with 45 CFR § 164.412, Business Associate may delay notifying Covered Entity for the applicable time period. Business Associate’s report will include at least the following, provided that absence of any information will not be cause for Business Associate to delay the report:

i. Identify the nature of the Breach, which will include a brief description of what happened, including the date of any Breach and the date of the discovery of any Breach;

ii. Identify the scope of the Breach, including the number of Covered Entity members involved as well as the number of other individuals involved;

iii. Identify the types of PHI that were involved in the Breach (such as whether full name, Social Security number, date of birth, home address, account number, diagnosis, or other information were involved);

iv. Identify who made the non-permitted use or disclosure and who received the non-permitted disclosure;

v. Identify what corrective or investigational action Business Associate took or will take to prevent further non-permitted uses or disclosures, to mitigate harmful effects, and to protect against any further Breaches;

vi. Identify what steps the individuals who were subject to a Breach should take to protect themselves;

vii. Provide such other information as Covered Entity may reasonably request.

c. Security Incident. Business Associate will promptly upon discovery of such incident report to Covered Entity any Security Incident of which Business Associate becomes aware. Business Associate will treat a Security Incident as being discovered as of the first day on which such incident is known to Business Associate, or by exercising reasonable diligence, would have been known to Business Associate. Business Associate shall be deemed to have knowledge of a Security Incident if such incident is known, or by exercising reasonable diligence would have been known, to any person, other than the person committing the Security Incident, who is an employee, officer or other agent of Business Associate. If any such Security Incident resulted in a disclosure not permitted by this Agreement or Breach of Unsecured PHI, Business Associate will make the report in accordance with the provisions set forth above.

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d. Mitigation. Business Associate shall mitigate, to the extent practicable, any harmful effect known to the Business Associate resulting from a use or disclosure in violation of this Agreement.

e. Breach Notification to Third Parties. Business Associate will handle breach notifications to individuals, the United States Department of Health and Human Services Office for Civil Rights, and, where applicable, the media. Should such notification be necessary, Business Associate will ensure that Covered Entity will receive notice of the breach prior to such incident being reported.

7. Term and Termination

a. The term of this Agreement shall be effective as of ___________, or Governor and Executive Council approval, and shall terminate on ____________ or on the date covered entity terminates for cause as authorized in paragraph (b) of this Section, whichever is sooner.

b. In addition to general provision #10 of this Agreement the Covered Entity may, as soon as administratively feasible, terminate the Agreement upon Covered Entity’s knowledge of a material breach by Business Associate of the Business Associate Agreement set forth herein as Appendix ___. Prior to terminating the Agreement, the Covered Entity may provide an opportunity for Business Associate to cure the alleged breach within a reasonable timeframe specified by Covered Entity. If Covered Entity determines that neither termination nor cure is feasible, Covered Entity may report the violation to the Secretary.

c. Upon termination of this Agreement for any reason, Business Associate, with respect to PHI received from Covered Entity, or created, maintained or received by Business Associate on behalf of Covered Entity, shall:

i. Retain only that PHI which is necessary for Business Associate to continue its proper management and administration or to carry out its legal responsibilities;

ii. Destroy, in accordance with applicable law and Business Associate’s record retention policy that it applies to similar records, the remaining PHI that Business Associate still maintains in any form;

iii. Continue to use appropriate safeguards and comply with Subpart C of 45 CFR Part 164 with respect to electronic PHI to prevent use or disclosure of the PHI, other than as provided for in this Section, for as long as Business Associate retains the PHI;

iv. Not use or disclose the PHI retained by Business Associate other than for the purposes for which such PHI was retained and subject to the same conditions set out in this Agreement which applied prior to termination; and

v. Destroy in accordance with applicable law and Business Associate’s record retention policy that it applies to similar records, the PHI retained by Business Associate when it is no longer needed by Business Associate for its proper management and administration or to carry out its legal responsibilities.

d. The above provisions shall apply to PHI that is in the possession of any Subcontractors of Business Associate. Further Business Associate shall require any such Subcontractor to certify to Business Associate that it has returned or destroyed all such information which could be returned or destroyed.

e. Business Associate’s obligations under this Section 7.c. shall survive the termination or other conclusion of this Agreement.

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8. Covered Entity’s Responsibilities

a. Covered Entity shall be responsible for the preparation of its Notice of Privacy Practices (“NPP”). To facilitate this preparation, upon Covered Entity’s request, Business Associate will provide Covered Entity with its NPP that Covered Entity may use as the basis for its own NPP. Covered Entity will be solely responsible for the review and approval of the content of its NPP, including whether its content accurately reflects Covered Entity’s privacy policies and practices, as well as its compliance with the requirements of 45 C.F.R. § 164.520. Unless advance written approval is obtained from Business Associate, Covered Entity shall not create any NPP that imposes obligations on Business Associate that are in addition to or that are inconsistent with the HIPAA Rules.

b. Covered Entity shall bear full responsibility for distributing its own NPP.

c. Covered Entity shall notify Business Associate of any change(s) in, or revocation of, permission by an Individual to use or disclose PHI, to the extent that such change(s) may affect Business Associate’s use or disclosure of such PHI.

9. Miscellaneous

a. Definitions and Regulatory References. All terms used, but not otherwise defined herein, shall have the same meaning as those terms in the HIPAA Rules as in effect or as amended.

b. Amendment. Covered Entity and Business Associate agree to take action to amend the Agreement as is necessary for compliance with the requirements of the HIPAA Rules and any other applicable law.

c. Business Associate shall make available all of its internal practices, policies and procedures, books, records and agreements relating to its use and disclosure of Protected Health Information to the United States Department of Health and Human Services as necessary, to determine compliance with the HIPAA Rules and with this Appendix ___.

d. Interpretation. The parties agree that any ambiguity in the Agreement shall be interpreted to permit compliance with the HIPAA Rules.

e. Severability. If any term or condition of this Appendix ___ or the application thereof to any person(s) or circumstance is held invalid, such invalidity shall not affect other terms or conditions which can be given effect without the invalid term or condition; to this end the terms and conditions of this Appendix ___ are declared severable.

f. Survival. Provisions in this Appendix ___ regarding the use and disclosure of PHI, return or destruction of PHI, confidential communications and restrictions shall survive the termination of the Agreement.

IN WITNESS WHEREOF, the parties hereto have duly executed this Appendix ___. The State of New Hampshire Employee and Retiree Health Benefit Program

Contractor

Signature of Authorized Representative Signature of Authorized Representative Name of Authorized Representative Name of Authorized Representative Title of Authorized Representative Title of Authorized Representative Date Date

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APPENDIX H

DATA REQUEST FORM

• Data

o Detailed Claims Experience for Repricing o Monthly Enrollment Counts o Top 100 Retail Brand Prescriptions o Top 100 Mail Brand Prescriptions

To obtain the RFP data, please complete this Data Request Form and send to Danielle Bishop at [email protected].

Data Request Form

We confirm that we are requesting this information for the sole purpose of responding to the State of New Hampshire’s Administration of Pharmacy Benefits RFP. As a recipient of this information, we will not use or disclose this information for any other purpose than to respond to the State's RFP. We will destroy this information upon the completion of the RFP process.

We confirm that our bid will meet the Minimum Qualifications identified in Section II.C of this RFP document.

We confirm:

� We are requesting this information for the sole purpose of responding to the State’s RFP;

� Our bid will meet the Minimum Qualifications and are prepared to provide documentation supporting this claim, if requested by the State, in order to receive the RFP data file; and

� Our bid will include complete response to all sections of this RFP.

Signed:

Print Name:

Title:

Phone Number:


State of New Hampshire Employee Health Benefit Program

Prescription Drug Benefits Booklet

Disclaimer: This document summarizes pharmacy benefit options offered by the State of New Hampshire

through Express Scripts. It is not a complete statement of the terms and conditions under which benefits

are available. This booklet is intended to describe benefits that are offered as accurately as possible.

Benefits are set forth in and governed by all applicable coverage documents. In the event of any

discrepancy between this booklet and the actual terms and conditions of those documents, the

documents will govern.

Reviewed by RMU February 2017

2 Back to Table of Contents


Table of Contents Your Pharmacy Benefit at a Glance .......................................................................................................... 5

2017 Copayments for Active Employees ............................................................................................... 5

Use of Generic Medications ................................................................................................................... 6

Maintenance Medications through Mail Order ....................................................................................... 6

Specialty Medications ............................................................................................................................ 6

Manage Your Pharmacy Benefits Online............................................................................................... 6

Understanding Your Pharmacy Benefits................................................................................................ 8

Who is Eligible for the Pharmacy Benefit Plan ...................................................................................... 8

What is Covered Under Your Pharmacy Plan ....................................................................................... 8

What is Not Covered .............................................................................................................................. 9

Express Scripts’ Preferred Drug List Exclusions ................................................................................... 9

Express Scripts’ Compound Management Solution .............................................................................. 9

Your Pharmacy Options .......................................................................................................................... 10

Mail Order Program: Express Scripts Pharmacy Home Delivery Service ........................................... 10

Mail Order Opt-Out Program ............................................................................................................... 12

Worry-Free Fills ................................................................................................................................... 12

Retail Pharmacy Program .................................................................................................................... 14

Express Scripts Specialty Pharmacy Program .................................................................................... 14

Other Important Pharmacy Program Information .................................................................................... 15

The Generic Drug Advantage .............................................................................................................. 15

Medications Preferred By Your Plan Design ....................................................................................... 15

Generic Step Therapy .......................................................................................................................... 16

Prior Authorization Requirements ........................................................................................................ 17

Quantity Limits ..................................................................................................................................... 18

Coverage of Preventive Medications ................................................................................................... 19

Appeal Administration .......................................................................................................................... 20

Coordination of Benefits ...................................................................................................................... 24

Express Scripts Contact Information ................................................................................................... 25

Other Things You Should Know .......................................................................................................... 27

APPENDIX............................................................................................................................................... 28

FAQs about Mail Order Pharmacy ....................................................................................................... 28

FAQs about Mail Order Packaging and Shipping ................................................................................ 29

FAQs about Express Scripts Worry-Free Fills® .................................................................................. 31

FAQs about Generic Medications ........................................................................................................ 33

FAQs about Generic Step Therapy ..................................................................................................... 34

FAQs about Prior Authorizations ......................................................................................................... 35

FAQs about Controlled Substances .................................................................................................... 37



Your Pharmacy Benefit at a Glance

Express Scripts administers the State of New Hampshire’s employee prescription drug benefits.

• This plan is subject to a “drug list” or “formulary”. This is a list of prescription drugs that are preferredby Express Scripts because of their safety, clinical effectiveness and ability to help controlprescription drug costs. The drug list is updated on a regular basis and can be found online atwww.Express-Scripts.com. You may also request a copy by calling Express Scripts Member Servicesat (866) 544-1798.

• This plan is not subject to a pharmacy deductible and does not have co-insurance.

• You are responsible for paying the applicable copayment for each prescription as listed on theExpress Scripts drug list. Copayments are the amount paid by you for each prescription, orauthorized refill. The copayments for each category provided below are based on a singleprescription, or refill.

• Annual Out-of-Pocket Maximums are the total copayments you, or your family, are required to pay ina calendar year. Once this amount is reached, the State will pay 100 percent of the cost of yourmedications through the remainder of the calendar year. The accumulated copayment amounts arereset to zero at the beginning of each calendar year.

• Each prescription shall not exceed the days’ supply limits listed below and is based on theprescriber’s dosage and quantity indicated on the prescription:

o Ninety (90) day supply for the Mail Order Program called the Express Scripts PharmacySM

Home Delivery Service,

o Thirty-one (31) day supply for the Retail Pharmacy Program.

o The days’ supply limit is subject to exceptions for the following:

- Certain pre-packaged drugs with greater than a 31-day supply which may require multiple copayments,

- Certain medications, like controlled substances, that have quantity limits on the amount dispensed as defined by federal regulations.

• All prescriptions have a maximum number of refills as specified by the prescriber and must berenewed at least every 12 months.

2017 Copayments for Active Employees

Retail Pharmacy Program Generic Drugs $10 copayment Preferred Brand-Name Drugs $25 copayment Non-preferred Brand-Name Drugs $40 copayment Certain Preventive Medications $0 copayment

Mail Order Program Generic Drugs $1 copayment Preferred Brand-Name Drugs $40 copayment Non-preferred Brand-Name Drugs $70 copayment Certain Preventive Medications $0 copayment

Annual Out-of-Pocket Maximum Individual $750 per person per calendar year Family $1,500 per family per calendar year


Use of Generic Medications

Your pharmacy plan requires that you use a generic medication when available. When a generic equivalent is available but the pharmacy dispenses the brand-name medication for any reason other than a doctor’s “dispense as written” (DAW) orders or similar instructions, you will pay the generic copayment plus the difference in full cost between the brand-name and the generic. The difference in payment will not count toward your annual out-of-pocket maximum.

When your doctor recommends the brand-name for treatment and includes the necessary instructions, you will pay the brand-name copayment as indicated above. (Also see the Generic Step Therapy section in this document for more information about using generic medications before requesting the brand name.)

Exception: If a generic medication is out of stock at the time a prescription is requested, Express Scripts may substitute the generic with a preferred brand, if it is available. The copayment will coincide with the original prescription requested.

Maintenance Medications through Mail Order

Your plan requires that maintenance or long-term medications be filled through the Express Scripts Pharmacy

SM Home Delivery Service. You are allowed one initial fill and two refills in a retail pharmacy

before you are charged the full price of the medication. Express Scripts will reach out to you by phone and by mail before you are charged the full price of the medication. (See the sections in this document on the Mail Order Program, the Retail Pharmacy Program, and the Mail Order Opt-Out Program for more information about your options to receiving your medications.)

Specialty Medications

Specialty medications must be filled through Accredo, the full-service Express Scripts specialty pharmacy. (See the Express Scripts Specialty Pharmacy Program section in this document for more information about your specialty pharmaceutical benefits.)

o For specialty prescriptions that must be filled more frequently or for a 31-day supply orless, you will be charged the retail copayment for each supply.

o If your specialty prescription can be filled every 90 days, or more than a 31-day supply,you will be charged the mail order copayment for each supply.

Manage Your Pharmacy Benefits Online

Although not required, you are encouraged to register for your own Express-Scripts.com online account as the website is referenced throughout this Benefit Booklet. To register, visit www.Express-Scripts.com and click on the “Register Now” orange icon on the home page. You will need your Express Scripts Member ID Card to register. You will fill out a brief registration form to ensure the security and privacy of your account. You will also be prompted to create a username and password (choose ones you will remember for logging on in the future).

Once you have reviewed all the information you have entered and made any necessary changes, you will need to read and accept the Express Scripts terms and conditions. It may be helpful to have a current prescription on hand when registering. Once online, you will have access to tools and resources that allow you to:

• Request mail order refills• Learn about medications and interactions• Compare brand-name and generic drug prices


• Check the status of mail orders • Check and pay mail order account balances • Locate a participating retail pharmacy • Review benefit plan highlights • Obtain order forms and claim forms • Request temporary Member ID cards

The home page of the Express Scripts website is designed to be a quick-access dashboard for your prescriptions. Under the Express Scripts logo at the top of the home page you will find several drop down menus that appear when you hover your mouse pointer over the words ‘Manage Prescriptions’, ‘Health & Benefits Information’, and ‘My Account’. You will also find quick links at the bottom of the home page (see insert below). Frequently Asked Questions (circled below) is where you will find answers to several topics including how to send a secure message to Express Scripts via the web. You are encouraged to explore the website for valuable resources available to you and your family.

Under the ‘My Account’ menu at the top of the Home page, choose the ‘Select Communication Preferences’ option. At the bottom of the screen under the ‘Your Preferences’ section of the page, click on the ‘Communication preferences’ link. Click on the ‘Edit preferences’ link in the top right hand corner of the ‘Viewing preferences’ window and the ‘Communication preferences’ window. In this window (depicted below), you may choose to include the name of the medications, patient names and full prescription numbers in email communications with Express Scripts.


Understanding Your Pharmacy Benefits It is recommended that you understand how your prescription benefits work and how your requests to fill prescriptions will be processed by Express Scripts. The ‘Price a Medication’ tool at www.Express-Scripts.com (found under the Manage Prescriptions drop down menu) provides the following information once you enter the name and dosage of the prescription you wish to fill:

• The copayment amount you will be charged; • If a generic equivalent or lower cost alternative is available; • If there are special requirements that must be met before a prescription can be filled:

o If a prior authorization or medical review is required from your doctor; o If you are required to try the generic first (generic step therapy); or o If there are quantity limits on the amount of medication that can be dispensed.

You may also request this information by calling Express Scripts Member Services at (866) 544-1798.

Who is Eligible for the Pharmacy Benefit Plan Eligibility for coverage under the State of New Hampshire pharmacy benefits is determined by the eligibility criteria set forth in the medical plan benefit book. Your enrollment in the plan is dependent on your enrollment election in the medical benefits. There are no separate enrollment forms to elect the pharmacy benefit.

What is Covered Under Your Pharmacy Plan Covered drugs which, under New Hampshire or federal law, require a prescription and are designated as part of the plan design outlined below. Excluded from covered drugs are: (i) cosmetic drugs; (ii) appliances, devices, bandages, heat lamps, braces, splints, and artificial appliances; and (iii) health and beauty aids, cosmetics, and dietary supplements, unless otherwise required by New Hampshire or federal law, and is a prescription drug provided through Express Scripts. All State of New Hampshire plan design options cover the following:

• State regulated drugs • Diabetes supplies, including insulin syringes • Insulin by prescription only • Federal legend drugs, including:

- Cardiovascular drugs - Anti-infectives - Dermatological therapies

- Ear, nose, and throat medications - Ophthalmology drugs - Respiratory, allergy, cough, and cold medications - Oral diabetes drugs - Growth hormones and injectables - Contraceptives and devices

• Emergency contraception medications (prescription and OTC) • Immunizing agents • Tobacco cessation medications, including over-the-counter products

Certain controlled substances, and other prescribed medications, may be subject to dispensing limitations and to the professional judgment of the pharmacist. Prescriptions for certain controlled substances may be shipped under separate cover. (See the section on Drug Quantity Limits for more information.) Under the Affordable Care Act (ACA), commonly known as health care reform, certain preventive medications, including over-the-counter (OTC) medications, are covered without charging a copayment, coinsurance or deductible (zero-dollar cost share). The State of New Hampshire Prescription Benefit


Program, in consultation with Express Scripts, has developed a list of medications and criteria (i.e., gender and age) to support preventive medication requirements based on the recommendations of the U.S. Preventive Services Task Force (USPSTF) and the Centers for Disease Control and Prevention (CDC) to be covered under the pharmacy benefit. If you meet the eligibility criteria for the zero-dollar cost share, Express Scripts will automatically waive your copayment based on the medication being prescribed, specific to age and gender requirements of the ACA for covered employees and their dependents. All medications will require a prescription, including over-the-counter medication. (See the section on ACA Preventive Medications for more information.)

What is Not Covered All plan design options exclude coverage for the following:

• Therapeutic devices or appliances; • Anti-Obesity medications; • Non–federal legend drugs, except insulin; • Drugs labeled “Caution—Limited by Federal Law to Investigational Use,” or experimental drugs,

regardless of whether a charge is made to the member; • Medication for which the cost is recoverable under any workers’ compensation or occupational

disease law or any state or government agency, or medication furnished by any other pharmaceutical or medical service for which no charge is made to the member;

• Medication taken or administered to the member while he or she is a patient in a licensed hospital, rest home, sanitarium, extended care facility, skilled nursing facility, convalescent hospital, nursing home, or similar institution that operates on its premises, or allows to be operated on its premises, a facility for dispensing pharmaceuticals;

• Any prescription that has reached the maximum number of refills specified by the physician, or any prescription that is more than one year old.

Express Scripts’ Preferred Drug List Exclusions Express Scripts has a list of medications that are not included on the Drug List. This list of drugs is called the Preferred Drug List Exclusions and can be found on www.Express-Scripts.com. (The list is located on the bottom of the home page in the Benefit & Account Notifications box.) These drugs are not covered due to their high cost and the availability of lower cost medications that are equal in clinical effectiveness. If you choose to fill this medication, you are subject to the full cost of the drug and the cost will not count toward your Annual Out-of-Pocket Maximum. Express Scripts recognizes that some physicians may still want to prescribe the medications on the Preferred Drug List Exclusions and may do so through the Prior Authorization process.

Express Scripts’ Compound Management Solution Certain compounded medications are excluded from coverage under the Plan. The Express Scripts’ Compound Management Solution uses the following criteria to determine medical necessity and if the compounded ingredients are covered:

• Availability of commercially alternative medications (FDA approved prescription); • Availability of an over-the-counter (OTC) alternative product; • Clinical evidence of safety and efficacy of the compounded ingredient(s); and • Whether an ingredient represents a significant cost or has significant and/or continuous price

increases. Express Scripts recognizes that some physicians may still wish to prescribe a compounded medication that includes one or more excluded ingredients. The prescriber should contact the Express Scripts’ Prescriber Assistance Department at 1 (888) 327-9791 for more information.


Your Pharmacy Options

Mail Order Program: Express Scripts Pharmacy Home Delivery Service Your plan requires that maintenance or long-term medications be filled through the Express Scripts Pharmacy


before you are charged the full price of the medication. Express Scripts will reach out to you by phone and by mail before you are charged the full price of the medication. All enrollees are offered the option of having their maintenance or long-term medications (those taken for 3 months or more) delivered to their home or other location. Medications are dispensed by the Express Scripts Pharmacy pharmacists through its network of mail order pharmacies. Mail Order Program Basics

• You may obtain up to a 90-day supply (compared with a typical 31-day supply at retail) of each covered medication for one mail order copayment. Registered pharmacists are available 24 hours a day, 7 days a week.

Express Scripts Home Delivery mail order pharmacies will not be required to dispense prescriptions for greater than a 90-day supply of covered drugs per prescription or refill, subject to the professional judgment of the dispensing pharmacist, limitations imposed on controlled substances, and the manufacturer’s recommendations. Prescriptions may be refilled provided it is stated in the prescription.

• Order refills online, by mail, or by phone—anytime day or night. To order online, register at www.Express-Scripts.com. Refills are usually delivered within 8 days after your request is received in good order.

A “request in good order” is a prescription that has all the proper medical authorizations in place and, based on the prescriber’s instructions, the remaining supply on hand from the previous refill has depleted to approximately 25% or two (2) weeks to ten (10) days.

• Payment Options— When using home delivery, you can pay by check, e-check (see below for additional information), money order or credit card. If you prefer to use a credit card, you have the option of joining Express Scripts’ automatic payment program by calling the self-service payment application at (800) 948-8779 or by enrolling online. If you prefer to speak to a live customer service representative, call 1 (866) 544-1798. Credit cards accepted include Visa, MasterCard, Discover, American Express, and Health Reimbursement (HRA) or Flexible Spending Account (FSA) debit cards.

E-check is another term for electronic fund transfer. When you pay for mail order prescriptions with e-check, your copayments are conveniently deducted from your checking account. There is a 10-day grace period between the time your order is sent and when the amount is deducted from the assigned checking account. (The amount that is being deducted will be included in the prescription information that accompanies your order.)

• Standard shipping is free.

• When it is time for you to renew your prescription (usually after one year), you can choose to obtain a new prescription from your doctor directly or request that Express Scripts reach out to your doctor for you by calling Express Scripts Member Services at 1 (866) 544-1798.

How to initiate the Mail Order Program There are several ways to initiate the use of mail order for your maintenance medications. The online method is the fastest and easiest way to initiate the mail order program. Online:


• Ask your doctor to write a prescription for up to a 31-day supply with enough refills for twelve (12) months and fill it immediately at your chosen local pharmacy.

• After you’ve filled your 31-day prescription, go to www.Express-Scripts.com. o It may take up to 48 hours for your medication to appear on your home page. o From your home page at Express-Scripts.com, scroll down to the Prescriptions section.

You will find a purple box entitled “Transfer to Home Delivery” under the prescription you filled at the retail pharmacy. Follow the directions on the page to initiate the transfer to mail order.

By mail:

• If you prefer to mail your written prescriptions directly to Express Scripts, you may do so by asking your doctor to write a prescription for up to a 90-day supply of each medication (plus refills for up to 1 year, if appropriate).

• If you are currently taking a medication, be sure to have at least a 14-day supply on hand when ordering. If you do not have enough, ask your doctor to give you a second prescription for up to a 31-day supply to fill at a participating retail pharmacy while your mail order prescription is being processed.

• You will need to include a completed Express Scripts Home Delivery mail order form with your written prescription.

o Express Scripts Home Delivery mail order forms can be found at www.Express-Scripts.com. They are available for printing under the Health & Benefits Information menu. Select ‘Print & Request Forms & Cards’ from the drop down menu.

o You may also call Express Scripts Customer Service at (866) 544-1798 to request mail order forms be mailed to you.

• Mail your prescriptions and completed mail order form(s) to the address listed on the mail order form. Appropriate US postage will be required.

• To help avoid delays in filling your prescription, be sure to include payment with your order. Payment options are listed on the mail order form.

By phone: • If you prefer to order your mail order prescriptions by phone, you can request that Express

Scripts contact your doctor directly to submit a prescription to the Mail Order Program on your behalf by calling (866) 544-1798.

• If you are currently taking a medication, be sure to have at least a 14-day supply on hand when ordering. If you do not have enough, ask your doctor to call in a second prescription for up to a 31-day supply to fill at a participating retail pharmacy while your mail order prescription is being processed.

• Be sure to have your identification number located on your Express Scripts prescription card, doctor’s name and medication name available at the time of your call.

By fax from your doctor:

• You may also have your doctor fax your prescriptions. Ask your doctor to call the Express Scripts Prescriber Assistance Line at 1 (888) 327-9791 for faxing instructions.

• Or you may print a mail order fax form for your physician to complete. The fax forms can be found at www.Express-Scripts.com under the Health & Benefits Information menu. Select ‘Print & Request Forms & Cards’ from the drop down menu.

• If you are currently taking a medication, be sure to have at least a 14-day supply on hand when ordering. If you do not have enough, ask your doctor to give you a second prescription for up to a 31-day supply to fill at a participating retail pharmacy while your mail order prescription is being processed.

• Note: Faxes must be sent from your doctor’s office. Faxes from other locations, such as your home or workplace, cannot be accepted.

You can expect new prescriptions to arrive 7-10 calendar days after Express Scripts receives your order. Refills are usually delivered within 8 days following Express Scripts’ receipt of your refill


request. Your medication will be mailed to your home via standard U.S. Postal Service at no charge and will arrive in a plain, weather and tamper-proof pouch, with packaging accommodations made for temperature control if needed. Overnight delivery is available, at an additional cost. The cost varies depending on the destination city and state.

Home Delivery Mail Order Program Copayments You will be responsible to pay the applicable copayment to Express Scripts for each prescription or authorized refill dispensed by Express Scripts under the mail order program. In those instances where your copayment would otherwise be greater than the pricing for any drug covered, you will pay the lower price. Express Scripts may suspend the mail order services to you if you are in default of any copayment amount due.

Mail order pharmacies will dispense covered prescription drugs to you, and dispense generic drugs when authorized, in accordance with applicable laws and regulations in the state in which the mail order pharmacy is located. All matters pertaining to the dispensing of covered drugs or the practice of the pharmacy in general, are subject to the professional judgment of the dispensing pharmacist. Any drug that cannot be dispensed in accordance with the manufacturer, or regulatory protocols, may be excluded from coverage by Express Scripts.

Mail Order Opt-Out Program Your plan includes the Mail Order Opt-Out program (Opt-Out) called the Express Scripts Select Active Choice Program. The Opt-Out program is designed to provide more flexibility in situations where mail order requirements create an undue hardship. The program provides you with the choice to fill maintenance or long-term prescriptions through Express Scripts Pharmacy Home Delivery Service or at a retail pharmacy location. If you elect to opt-out of the mail order program:

• You will not be subject to the plan’s requirement to fill maintenance or long-term prescriptions through mail order after three fills (one initial fill plus two refills) at the retail pharmacy.

• You may only receive up to a 31-day supply at a retail pharmacy. • You will pay the plan’s retail copayment. • You can still choose to fill your prescriptions through mail order, even if you elect to opt-out. • Obtain new prescriptions for medications you wish to fill at a retail pharmacy. When you opt-out of

the mail order program, your election applies to all current medications and future prescriptions.

The opt-out feature does not apply to specialty medications. Specialty prescriptions are provided through Accredo Health Group, Inc., an Express Scripts specialty pharmacy (please see Express Scripts Specialty Pharmacy Program explanation below). To opt-out of the plan’s requirement to fill maintenance or long-term prescriptions through mail order after three fills at the retail pharmacy, call Express Scripts toll-free at 1 (877) 603-1032 and provide your identification number located on your prescription drug card. Spouses and dependent children age 18 and older must call separately to opt-out.

Worry-Free Fills You can request automatic refills of your mail order medications through the Worry-Free Fills Program online at www.Express-Scripts.com at the time you fill your prescription or by calling Express Scripts at 1 (866) 544-1798. The Worry-Free Fills program is a service that offers you the convenience of automatically sending your next month’s refill once your estimated remaining days’ supply reaches ten (10) days. You will receive a call seven (7) days prior to shipment to notify you that your medication is being shipped.

A prescription is eligible for the Worry-Free Fills program if:


1) It is dispensed by the home delivery Express Scripts Pharmacy,2) You have taken the medication for a minimum of 30 days,3) The prescription will not expire before your next refill, and4) It is for at least a 56 day supply.

Certain drugs, such as controlled substances, over-the-counter medications, and specialty drugs, are not eligible for the Worry-Free Fills program.

Starting Worry-Free Fills

If you wish refill a prescription automatically through the Worry-Free Fills program, you may do so at the time you place your order online if your medication meets the eligibility criteria. When ordering, make sure there is a check mark in the box that says: ‘Automatically refill this prescription from now on with Worry-Free Fills’ on the ‘Review Your Order’ page. Express Scripts will automatically send you your next refill. You can also enroll your eligible prescriptions by calling the toll-free Member Services phone number 1 (866) 544-1798.

Please note that certain medications are not eligible for Worry-Free Fills. The Worry-Free Fills option is not displayed if the medication is not eligible. To find out if any of the prescriptions you are currently taking are eligible for Worry-Free Fills, go to www.Express-Scripts.com, under the ‘Manage Prescriptions’ menu, choose ‘Manage Automatic Refills’ to access the Worry-Free Fills program management page.

From the Worry-Free Fills program management page online, you may choose to enroll all current and future medications eligible for the Worry-Free Fills program or just specific medications. This is the same location where you can turn off Worry-Free Fills. You may also enroll or cancel Worry-Free Fills by calling the toll-free Member Services phone number 1 (866) 544-1798.

Canceling Worry-Free Fills

You may remove a prescription from the Worry-Free Fills program at any time without cancelling the current order through the Worry-Free Fills program management page (described above) and clicking on the "Turn off Worry-Free Fills for this Prescription" link next to the medication you want to remove from Worry-Free Fills or call the toll-free Member Services phone number 1 (866) 544-1798.

Removing a prescription from the Worry-Free Fills program will not cancel the pending order. However, you will need to order any subsequent refills online, call 1 (866) 544-1798, or mail in a refill slip with an order form.

See the Appendix for Frequently Asked Questions (FAQs) for Worry-Free Fills if you require more information.

IMPORTANT NOTE: If you are no longer taking a prescription or your dosage has changed, it is important that you contact Express Scripts immediately to turn off automatic refills to avoid any unnecessary fills and wasted medication. Even though you may only be paying a small copayment for your prescription, the actual cost for the medication is likely to be hundreds, if not thousands of dollars charged to the State.

Notify Express Scripts immediately to help avoid wasteful spending and unwanted medications by turning off Worry-Free Fills when no longer needed.


Retail Pharmacy Program You can use a participating retail pharmacy for short-term prescriptions (such as antibiotics to treat infections) or other non-maintenance medications (such as sleep agents and pain relief). You may obtain up to a 31-day supply of covered medication for each prescription or refill. Be sure to show your Express Scripts member ID card at the pharmacy and pay your retail copayment for each prescription. You may fill maintenance or long-term prescriptions at the retail pharmacy for up to three fills (one initial fill plus two refills). For additional fills, the plan requires you to fill maintenance or long-term prescriptions through the mail order program. If you choose to fill your maintenance or long-term prescriptions at the retail pharmacy after the three fills allowed by the plan, you will be responsible for 100% of the medication’s cost unless you elect to opt-out of mail order (please see Mail Order Opt-Out Program section for more information). If the total cost for your prescription is less than the applicable copayment, you will pay the lesser cost. At the point of sale, your payment will not be greater than the Usual and Customary (U & C) price of the participating pharmacy. The U & C price means the usual and customary retail price charged by a participating pharmacy to individual retail customers in the ordinary course of business for a prescription or refill. In those instances where your copayment would otherwise be greater than the U & C Price of the participating pharmacy, you will pay only the U & C cost. Participating pharmacy means a retail pharmacy that has entered into an arrangement with Express Scripts to participate in Express Scripts’ Network. The network of participating pharmacies that comprises Express Scripts’ network may be modified from time to time. To find a participating Express Scripts pharmacy go to www.Express-Scripts.com under the ‘Manage Prescriptions’ menu, choose the ‘Locate a Pharmacy’ link or call Express Scripts Member Services at 1 (866) 544-1798. A non-participating pharmacy is a licensed retail pharmacy that is not a participating pharmacy. If you use a non-participating retail pharmacy, you must pay the entire cost of the prescription and then submit a reimbursement claim to Express Scripts by completing the Express Scripts Coordination of Benefits/Direct Claim Form. This form is found at http://www.Express-Scripts.com under the ‘Health & Benefits Information’ menu. Select ‘Print & Request Forms & Cards’ from the drop down menu. The form can be requested by calling Express Scripts Customer Service at 1 (866) 544-1798. Claims must be submitted within 365 days of the prescription purchase date. When you use a non-participating pharmacy, you will be reimbursed the amount the drug would have cost at a participating retail pharmacy, minus your retail copayment. To find a participating retail pharmacy near you:

• Log-on to www.Express-Scripts.com, under the ‘Manage Prescriptions’ menu, choose the ‘Locate a Pharmacy’ link.

• Ask at your retail pharmacy whether it participates in the Express Scripts network.

Express Scripts Specialty Pharmacy Program Accredo specialty pharmacy is a mail order facility dedicated to dispensing specialty medications. Some conditions, such as multiple sclerosis, Hepatitis C, rheumatoid arthritis, cystic fibrosis, infertility, pulmonary hypertension, RSV prophylaxis, Gaucher disease, and growth hormone deficiency, are treated with specialty drugs. Specialty drugs means those pharmaceutical products that are generally biotechnical in nature, with many requiring injection, or other non-oral methods of administration, and that have special shipping or handling requirements.


Members who are eligible for services through Accredo will receive support from pharmacists and nurses who are trained in specialty medications, their side effects, and the conditions they treat. Also, because many of these medications require injection or special handling, members will receive:

• Expedited shipping of specialty medications to their home or doctor's office, where allowable by law.

• Supplemental supplies, such as needles and syringes, that are needed to administer the medication.

• Scheduling of refills and coordination of services with home care providers, case managers, and doctors or other healthcare professionals.

All specialty medications will be provided by Accredo Health Group, Inc., through Express Scripts Specialty Pharmacy Program and require Prior Authorization. If you are prescribed a specialty medication you should contact Express Scripts Specialty Pharmacy at 1 (800) 803-2523. Emergency or urgent supplies may be filled at the retail pharmacy only by contacting Express Scripts Specialty Pharmacy at 1 (800) 803-2523. Your copayments are determined by the day supply dispensed for specialty prescriptions. If your prescription is filled monthly or more frequently (a 31-day supply or less), the retail pharmacy copayment will apply. If your prescription can be filled for more than a 31-day supply, the mail order copayment will apply. For additional information, call the Express Scripts at 1 (800) 803-2523. If your provider needs to contact Accredo directly, they can call Accredo at 1 (800) 987-4904 (option 5) or they can fax a specialty prescription to 1 (800) 391-9707.

Other Important Pharmacy Program Information

The Generic Drug Advantage Generic drugs may have unfamiliar names, but they are safe and effective substitutes to brand name medications without the brand name cost. There are two types of generic medications: generic equivalents and generic alternatives.

• A generic equivalent is a medication that contains the same active ingredient and strength as the brand name drug.

• A generic alternative is a medication that contains a different active ingredient then the brand name drug but is clinically proven to treat the same condition.

Both types of generic medications are manufactured according to the same federal regulations. Prescriptions filled with generic drugs often have a lower copayment. Therefore, you may be able to obtain the same health benefits at a lower cost. You should ask your doctor, or pharmacist, whether a generic equivalent or alternative drug would be right for you. You may be able to receive the same treatment results and reduce your expenses.

See the Appendix for Frequently Asked Questions (FAQs) on Generic Medications if you require more information.

Medications Preferred By Your Plan Design The State of New Hampshire’s prescription drug benefit program includes a list of prescription drugs, called the National Preferred Formulary, that are preferred by Express Scripts because of their safety,


clinical effectiveness and ability to help control prescription drug costs. This drug list has a wide selection of generic and brand-name medications that have been evaluated for inclusion by a panel of physicians and pharmacists. The drug list may be modified by Express Scripts from time to time as a result of factors including, but not limited to, medical appropriateness, manufacturer rebate arrangements, and patent expirations. On an annual basis, Express Scripts makes modifications to their National Preferred Formulary. These changes are based on recommendations from the panel of physicians and pharmacists who continually review and compare the medications, including new drugs and generics. As a result, some safe and effective drugs become “preferred” and others may become “non-preferred.” If a change to the formulary results in an increased copayment or a change in coverage, Express Scripts will communicate the changes with you as well as participating pharmacies and/or physicians. At that time, you will be provided with a more cost effective preferred option to your medication. You should talk to your provider to determine which medication is right for you. If your provider determines that you must continue taking the non-preferred brand, you will be responsible for the higher copayment amount. Express Scripts also determines if medications are excluded from the formulary drug list. A list of these medications can be found on www.Express-Scripts.com, under the Benefit & Account Notifications box at the bottom of the home page. In most cases, if you fill one of these prescriptions, you will be responsible to pay the full retail cost of the drug. The list of excluded medications is subject to the same annual review and notification process as mentioned above. If your provider believes that your treatment requires one of the excluded medications, a prior authorization is required. To initiate the prior authorization process, ask your provider to contact Express Scripts at 1 (800)753-2851. For additional information about Express Scripts’ formulary, go to www.Express-Scripts.com, under the ‘Manage Prescriptions’ menu, select the ‘Price a Medication’ link or call Express Scripts toll-free at 1 (866) 544-1798.

Generic Step Therapy For certain brand-name medications, your plan requires you to try a generic equivalent medication, or front-line drug, first before your fill the more expensive brand name drug. Brand-name medications, or back-up drugs, will be covered under your plan if your prescription history shows within a specific time period that you have tried a generic equivalent. This is called Generic Step Therapy. Generic Step therapy is a program for people who take prescription drugs regularly to treat a medical condition, such as arthritis, asthma or high blood pressure. It allows you and your family to receive the affordable treatment you need and helps the State minimize prescription drug costs. In step therapy, drugs are grouped in categories, based on treatment and cost:

• Front-line drugs — the first step — are generic and sometimes lower-cost brand drugs proven to be safe, effective and affordable. In most cases, you will be required to try these drugs first because they usually provide the same health benefit as a more expensive drug, at a lower cost.

• Back-up drugs — Step 2 and step 3 drugs — are brand-name drugs that generally are necessary

for only a small number of patients. Back-up drugs are the most expensive option. Always talk with your doctor to determine if the generic equivalent is appropriate for you. If your doctor determines the generic is not effective for you because of a medical condition or allergy, or you have tried the recommended generic equivalent in the past with unsuccessful results, ask your doctor to contact Express Scripts at 1 (800) 753-2851 to request a Prior Authorization (PA). If the PA is approved, the brand-name medication, as prescribed by your doctor, will be covered and you will be charged the applicable brand-name copayment. If the PA is not approved, you will be required to


pay the full cost of the brand-name medication or you can consider changing to an equivalent generic upon further discussions with your doctor. Please note the additional cost you pay will not apply toward your calendar year out-of-pocket maximum. The first time you submit a prescription that has a generic equivalent available and is subject to step therapy, you will be informed by the pharmacy that you need to first try a front-line drug if you don’t want to pay full price for your prescription drug. To receive a front-line drug:

• Ask your pharmacist to call your doctor and request a new prescription for a front-line drug, or • Contact your doctor to get a new prescription for a front-line drug.

Only your doctor can change your current prescription to a front-line drug or request a prior authorization for the medication to be covered by your program. For additional information about Express Scripts’ formulary drugs that require step therapy, go to www.Express-Scripts.com, under the ‘Manage Prescriptions’ menu, select the ‘Price a Medication’ link or call Express Scripts toll-free at 1 (866) 544-1798.

See the Appendix for Frequently Asked Questions (FAQs) on Generic Step Therapy if you require more information.

Prior Authorization Requirements Prior authorization is a program that helps you get prescription drugs you need with safety, savings and – most importantly – your good health in mind. It helps you get the most from your healthcare dollars with prescription drugs that work well for you and that are covered by your prescription benefit. It also helps control the rising cost of prescription drugs for everyone in your plan. The program monitors certain prescription drugs and their costs so you can get the right medication at the right cost. It works much like healthcare plans that approve certain medical procedures before they’re done, to make sure you’re getting tests you need. If you’re prescribed a certain medication, it may need a prior authorization. A prior authorization makes sure you’re getting a cost-effective prescription drug that works for you. For instance, prior authorization ensures that covered medications are used for treating medical problems rather than for other purposes. Example: A medication may be in the program because it treats a serious skin condition, but it could also be used for cosmetic purposes, such as reducing wrinkles. To make sure your medication is used to treat a medical condition and promote your health and wellness, your plan may cover it only when a doctor prescribes it for a medical problem. Express Scripts consults with your medical professional. If you’re told that your prescription needs a prior authorization, it simply means that more information is needed to determine if your medication can be covered. Only your doctor (or sometimes a pharmacist) can provide this information and request a prior authorization. Your plan requires prior authorization for the following prescription medications:

• Erythroid stimulants • Injectable Fertility agents (except Oral Fertility Medications) • Growth hormones • Interferon agents • Multiple sclerosis agents


• Myeloid stimulants • Platelet Proliferators • Injectable Rheumatoid Arthritis Agents • Xolair • Raptiva • Tysabri • Apokyn • Wellbutrin and its generics • Botox and Myobloc for non-cosmetic purposes

If you submit a prescription for a medication that requires prior authorization, your pharmacist will tell you that approval is needed before the prescription may be filled. The pharmacist will recommend that you ask your doctor to call the toll-free number 1 (800)753-2851 to request a prior authorization approval. If you use the Mail Order Program, your doctor will be contacted directly. When a prior authorization is triggered, more information is needed to determine whether your use of the medication meets your plan’s coverage conditions. You and your doctor will be notified of the decision in writing. If coverage is approved, the letter will indicate the amount of time for which coverage is valid, typically not more than one year or twelve (12) months. If coverage is denied, an explanation will be provided, along with instructions on how to submit an appeal. Only your doctor can request or renew a prior authorization for the medication to be covered by your program. For additional information about Express Scripts’ formulary drugs that require prior authorization, go to www.Express-Scripts.com, under the ‘Manage Prescriptions’ menu, select the ‘Price a Medication’ link or call Express Scripts toll-free at 1 (866) 544-1798.

See the Appendix for Frequently Asked Questions (FAQs) on Prior Authorizations if you require more information.

Quantity Limits Your plan includes quantity limits for certain medications limiting the amount of medication for which your plan will pay. Quantity limits help to ensure you receive your medications in amounts approved by the U.S. Food and Drug Administration to safely and effectively treat your condition(s). It helps to address patient safety concerns and prevent potential for abuse and misuse. To verify if the medication being prescribed by your doctor has a quantity limit visit Express Scripts at www.Express-Scripts.com or call Express Scripts toll-free at 1 (866) 544-1798. The limits do not prevent you from obtaining additional quantities as prescribed by your doctor. Your plan will pay for additional quantities if your doctor documents that they are clinically appropriate for treatment. If your prescription exceeds the quantity limits allowed by the plan, talk with your doctor to determine what quantities are effective for treatment. Ask your doctor to call Express Scripts at 1 (800)753-2851 to request a Prior Authorization (PA) if he/she determines additional medication is appropriate. If the PA is approved, the additional quantity as prescribed by your doctor may be obtained and you will pay the applicable copayment for the additional medication. If the PA is not approved, you will pay 100 percent of the cost for the additional quantities if you choose to obtain the additional supply at a retail pharmacy location. Please note the additional cost you pay will not apply toward your calendar year out-of-pocket maximum. For additional information about Express Scripts’ formulary drugs that require quantity limits, go to www.Express-Scripts.com, under the ‘Manage Prescriptions’ menu, select the ‘Price a Medication’ link or call Express Scripts toll-free at 1 (866) 544-1798.


Coverage of Preventive Medications Under the Affordable Care Act (ACA), commonly known as health care reform, certain preventive medications, including over-the-counter (OTC) medications, are covered without charging a copayment, coinsurance or deductible. Your plan, in consultation with Express Scripts, has developed a list of medications and criteria (i.e., gender and age) to support preventive medication requirements based on the recommendations of the U.S. Preventive Services Task Force (USPSTF) and the Centers for Disease Control and Prevention (CDC) to be covered under the pharmacy benefit. Your plan will provide medications in the drug categories listed below at no-cost share ($0 copayment) specific to age and gender requirements of the ACA*. All medications require a prescription, including over-the-counter medication. Drug or Drug Category Criteria

Aspirin (to prevent cardiovascular events)

Men ages 45 to 79 years and women ages 55 to 79 years Generic OTC < or = to 325mg

Aspirin for Preeclampsia Women < 55 years Generic only, low dose 81 mg, after 12 weeks gestation in women at high risk for preeclampsia

Fluoride Children older than 6 months of age through 5 years old Generic only (OTC and prescription products)

Folic Acid Women through age 50 years Generic only (OTC and prescription products) 0.4 – 0.8 mg

Iron Supplements Children ages 6 months to 12 months who are at risk for iron deficiency anemia Generic only (OTC and prescriptions products)

Smoking Cessation

Age limit 18 or older. Prior Authorization required for Wellbutrin and its generics, as these medications are not approved by the FDA for tobacco treatment. Generic prescriptions, generic OTC medications including patches and gum and Chantix.

Vitamin D Men and Women ages 65 or older Generic OTC and prescription products

Women’s Preventive Services & Contraception Coverage

Women through age 50 1) Barrier contraception – i.e. cervical caps, diaphragms 2) Hormonal contraception (generic and select brands) - oral, transdermal,

intravaginal, injectable 3) Emergency contraception 4) Implantable medications 5) Intrauterine contraception 6) OTC barrier contraceptive methods (with a prescription)

Breast Cancer Primary Prevention (Tamoxifen or Raloxifene)

High-risk women age 35 or older who do not have breast cancer or have never been diagnosed with breast cancer, ductal carcinoma in situ (DCIS), or lobular carcinoma in situ (LCIS) and with an estimated 5-year risk of 3% or greater (based on breast cancer risk model estimates). Physician must request review process to determine eligibility for $0 cost share.

Bowel Preparation for Colonoscopy Screening

Men and women ages 50 through 75 years. Generic and brand prescription and OTC preparations. Two prescriptions per 365 days.

Immunizations/Vaccinations Recommended ages per Advisory Committee on Immunization Practices


*The government guidelines are updated periodically to reflect new scientific and medical advances, so this list may be subject to change.

For additional information about Express Scripts’ formulary drugs that have a $0 copay, go to www.Express-Scripts.com, under the ‘Manage Prescriptions’ menu, select the ‘Price a Medication’ link or call Express Scripts toll-free at 1 (866) 544-1798.

Appeal Administration When a member or physician requests an appeal and additional information is provided, it is reviewed and evaluated by the Express Scripts Appeals Unit to determine if the drug use meets coverage conditions specified or intended by the State of New Hampshire Prescription Drug Program according to the procedures set forth below. Appeal decisions are made by a pharmacist, prescription benefit specialist or panel of clinicians. The Express Scripts appeal unit may also decide to forward a first level or second level appeal to a third party utilization management company (Independent Review Organization) for review and decision. Appeal procedures apply to appeals of adverse benefit determinations based on medical necessity, appropriateness or effectiveness of a covered benefit. The external review coordination procedures apply to appeals of adverse benefit determinations based on medical necessity, appropriateness or claims involving medical decision making after all internal levels of appeal process have been exhausted. Appeals Related to Eligibility Appeals related to eligibility to participate in the plan and related to plan design are coordinated by State of New Hampshire Division of Personnel at:

State of New Hampshire Division of Personnel

28 School Street Concord, NH 03301-6313

Phone: (603) 271-3262 FAX: (603) 271-1422

TDD Access: Relay NH 1-800-735-2964

Rescission of Coverage Rescission of Coverage is subject to the same rescission of coverage provisions in the medical plan benefit booklet. Express Scripts completes appeals per business policies that are aligned with state and federal regulations. Appeal decisions are made by an Express Scripts Pharmacist, Physician, and panel of clinicians or independent third party utilization management company. Submitting a Request for Appeal Other than appeals related to eligibility to participate in the plan, written requests for appeal should be mailed to:

Express Scripts 6625 W 78

th St

Bloomington, MN 55439

Attn: Appeals Team If you have questions about the appeals process, call the toll-free Member Services phone number on the back of your Express Scripts member ID card or 1 (866) 544-1798.


Level 1 Appeals To initiate a level 1 appeal, a Plan Participant (all references to Participant in the Appeals section of this Benefit Booklet include the Employee and/or covered Dependents) must submit a written request for an appeal to Express Scripts within one hundred eighty (180) days of receipt of a notice of denial of medication(s) under the Plan. The Participant must tell, or present evidence, e.g. documents, and testimony to, Express Scripts the reason why the denial should be overturned and include any information supporting the appeal. Express Scripts will evaluate or forward the appeal request and all accompanying information to the appropriate review entity. For standard cases, the Participant will receive in writing within one (1) working day an acknowledgement of receipt of the appeal request which includes allowance of five (5) business days for the Participant to submit any additional information. The acknowledgement letter will also contain the contact information for the person who is handling the appeal. Level 2 Appeals To initiate a level 2 appeal, a Plan Participant must submit a written request for an appeal to Express Scripts within ninety (90) days of receipt of an adverse determination of a Level 1 appeal under the Plan. The Participant must tell, or present evidence, e.g. documents, and testimony to, Express Scripts demonstrating the reason why the denial should be overturned and include any information supporting the appeal. Express Scripts will evaluate or forward the appeal request and all accompanying information to the appropriate review entity. Express Scripts completes appeals per business policies that are aligned with state and federal regulations. Appeal decisions are made by an Express Scripts Pharmacist, Physician, a panel of clinicians, or independent third party utilization management company. For standard cases, the Participant will receive in writing within one (1) working day an acknowledgement of receipt of the appeal request which includes allowance of five (5) business days for the Participant to submit any additional information. The acknowledgement letter will also contain the contact information for the person who is handling the appeal. Time frames for Processing Appeals of Pharmaceutical Adverse Determinations Standard Appeals: Standard, non-expedited Level 1 appeals involving the review of a denial of coverage for medication requests will be completed within 15 calendar days for pre-service appeals and 30 calendar days for post-service appeals. The appeal review period may be extended for a maximum of ten (10) calendar days if:

1) there is reasonable cause beyond the reviewer’s control for the delay; 2) can show that the delay will not result in increased medical risk to the Participant; and 3) provide a written progress report to the Participant and the related provider within the forty

(40) day review period. Participants must agree, in writing, to a request to extend a deadline. Expedited Appeals: Some appeals of denials relating to claims involving urgent pharmaceutical care are processed on an expedited basis. Expedited decisions are made when: • a Participant’s life or health or ability to regain maximum function would be jeopardized by following

the standard appeal process and time frames; or • in the opinion of an attending provider with knowledge of the Participant’s medical condition, delay

would subject the Participant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

Provider Requests In cases that require an expedited decision of a medication request, based at the request of an attending provider, a decision will be made within seventy-two (72) hours of the receipt of the request or more rapidly depending on medical exigencies.


Participant Requests If a Participant requests an expedited decision, the request will be reviewed. If it is determined that the request for an expedited appeal is medically necessary, a decision will be made within seventy-two (72) hours of the request or more rapidly depending on medical exigencies. All required information will be transmitted between the reviewer, the applicable provider, and the Participant by the quickest means possible. If it is determined that a request for an expedited appeal is not medically necessary, the Participant will be notified and the appeal processed within fifteen (15) calendar days. Internal Review of Appeal of Adverse Determination Clinical appeals (claims involving medical judgment) will be reviewed by an Express Scripts Pharmacist, Physician, panel of clinicians or independent third party utilization management company. The reviewer will represent the same or similar specialty of the prescribing physician and/or with training and experience in the relevant field, not involved in the initial determination, nor by a subordinate of the person resolving the claim initially or who has any conflict of interest. Administrative appeals (no medical decision making) will be reviewed by an Express Scripts pharmacist consultant not involved in the initial determination, nor by a subordinate of the person resolving the claim initially or who has any conflict of interest. The consultant will re-review the request to make a determination regarding whether the requested health care services are medically necessary and/or covered under the Plan. Notice of Decision on Appeal of Adverse Determination If the reviewer consultant decides to reverse an initial adverse determination, the reviewer will approve coverage of the medication. The applicable Participant and the applicable provider will be notified by mail or electronic means (fax) within seventy-two (72) hours of such decision. If the reviewer consultant decides to uphold an initial adverse determination, the applicable Participant and the applicable provider will be notified that the adverse determination has been upheld by written or electronic means within seventy-two (72) hours of such decision. Written notification must be provided in a linguistically appropriate manner. The Participant will be given appeal rights to pursue an External Review. Where there is an ongoing course of treatment that is the subject of the denied claim and an internal appeal, the plan will not reduce or terminate coverage of the treatment pending the outcome of the appeal. External review If the Participant is dissatisfied with any internal appeals decision for clinical claims (claims involving medical decision making), the Participant may request an external review by an Independent Review Organization (IRO) as defined by Applicable Law. An IRO is an independent review organization, external to the State of New Hampshire and Express Scripts, that utilizes independent physicians with appropriate expertise to perform external reviews of appeals. The IRO will, with respect to claims involving investigational or experimental treatments, ensure adequate clinical and scientific experience and protocols are taken into account as part of the External Review process. In rendering a decision, the IRO will consider any appropriate additional information submitted by the Participant and will follow the plan documents governing the Participant’s benefits. For claims involving urgent care, a Participant may request an expedited external review if the adverse benefit determination involves:

• a medical condition of the Participant for which the regular time frame would seriously jeopardize the life or health of the Participant or would jeopardize the Participant’s ability to regain maximum function, and

• the Participant filed a request for an expedited internal appeal; Or, if the final internal adverse benefit determination involved: • a situation where the Participant had a medical condition where that time frame would pose such

jeopardy, and


• if the final internal adverse benefit determination concerned an admission, availability of care, continued stay or health care service for which the Participant received emergency services and was not discharged from a facility.

Individuals in urgent care situations and individuals receiving an ongoing course of treatment may proceed with an expedited external review by an IRO at the same time as the internal review process occurs. There are no fees or costs imposed on a Participant for the external review of an appeal. The Participant’s decision as to whether or not to submit a denied appeal for external review will have no effect on the Participant’s rights to any other benefits under the Plan. When an appeal is denied by Express Scripts or a reviewer consultant, the Participant will receive a letter that describes the process to follow if the Participant wishes to pursue an external review of an appeal through an IRO. If a Participant files a request for an external review of an appeal with an IRO:

• The external review may only be requested after exhaustion of the required Internal Appeal procedures under the Plan, unless an expedited external review of a claim involving urgent care or an ongoing course of treatment is requested. Accordingly, the Participant must first submit an appeal with Express Scripts and receive a denial of appeal before requesting an external review of an appeal with an IRO.

• After a Participant receives a denial of an appeal, the Participant must submit the request for external review of appeal with an IRO in writing within 4 months from the date of receipt of the adverse benefit determination, extended to the next working day if the date falls on a weekend or federal holiday.

• The IRO will forward a copy of the final appeal denial letter and all other pertinent information that was reviewed in the appeal to the IRO. The Participant may also submit additional information to be considered. For standard non-expedited appeals, the Participant will have ten (10) business days to submit additional information to the IRO.

• Within five days after receipt of the request for external review, the Plan will complete a preliminary review to determine if the Participant was covered under the Plan at the time the service was requested or provided; whether the adverse benefit determination relates to the Participant’s failure to meet the eligibility requirements of the Plan; whether the Participant has exhausted the Plan’s internal appeal process; and whether the Participant has provided all of the information and forms required to process an external review. Within one business day after completion of this preliminary review, the Plan will provide the Participant written notification giving any reasons for the ineligibility of the request for external review and describing the information or materials required, and the Plan will allow the Participant to perfect a request for external review within the four month filing period or within the 48 hour period following receipt of the notification, whichever is later.

• The Participant will be notified of the decision of the IRO within 45 days of the receipt of the request for the external review of an appeal for standard, non-urgent claims. The IRO’s decision will include:

a) A general description of the reason for the request for external review;

b) The dates the IRO received the assignment to conduct the external review and the date of their decision;

c) Reference to the evidence or documentation, including specific coverage provisions and evidence-based standards, considered in reaching their decision, taking into account


adequate clinical and scientific experience and protocols with respect to claims involving experimental of investigative treatments;

d) A discussion of the principal reason or reasons for its decision, including the rationale for its decision;

e) A statement that judicial review may be available; and

f) Current contact information, including the phone number for any ombudsman established under the PHS Act.

g) In the event of an expedited external appeal for claims involving urgent care, the IRO will make the decision as expeditiously as the Participant’s medical condition or circumstances require, but in no event more than 72 hours after the IRO receives the request for an expedited external review and, if the notice is not in writing, within 48 hours after the date of providing the verbal notice, the IRO will provide written confirmation of the decision to the Participant and the Plan. Written notice must be provided in a linguistically appropriate manner. The notice will provide the opportunity to request diagnosis and treatment codes and their meanings.

h) The decision of the IRO will be binding on the Participant as well as the Plan, except to the extent there may be other remedies available under state law.

• The statute of limitations or other defense based on timeliness is suspended during the time that an external review of your appeal is pending.

Experimental or Investigational Services/Treatment Exclusions Experimental or investigational services/treatments are not covered benefits. Experimental/investigational means any treatment, procedure, facility, equipment, drug, device or supply not accepted as standard medical practice in the state services are provided. In addition, if a federal or other governmental agency approval is required for use of any items and such approval was not granted at the time services were administered, the service is experimental. To be considered standard medical practice and not experimental or investigational, treatment must meet all five of the following criteria:

1. A technology must have final approval from the appropriate regulatory government bodies; 2. The scientific evidence as published in peer-reviewed literature must permit conclusions

concerning the effect of the technology on health outcomes; 3. The technology must improve the net health outcome; 4. The technology must be as beneficial as any established alternatives; and 5. The improvement must be attainable outside the Investigational settings.

Coordination of Benefits Coordination of Benefits is the process in which two or more health insurers cover the same person(s) but limit the total benefit payable for a claim to an amount not exceeding the total cost of the claim. If any covered dependents have primary prescription drug coverage through another employer-sponsored plan, Medicaid or Medicare, you have the ability to submit deductibles, copayments, or co-insurance not covered by the primary plan for reimbursement under this plan. Reimbursement will be provided for covered drugs as outlined in the “What is Covered” section of this Benefits Booklet and subject to any plan design limitations. Reimbursement should be requested by completing the Express Scripts Prescription Drug Reimbursement/Coordination of Benefits Claim Form found on www.Express-Scripts.com under the Health & Benefits Information menu. Select ‘Print & Request Forms & Cards’ from the drop down menu. The form can be found and printed under the ‘Claim forms for retail pharmacy purchases’ section. You may also have a form mailed to you by calling Member Services at 1 (866) 544-1798.


You must first submit the claim to the primary insurance carrier. Once the statement from the primary plan is received from the primary carrier, complete the Prescription Drug Reimbursement/Coordination of Benefits Claim Form, tape the original prescription receipts in the spaces provided at the top of this page, and attach the statement from the primary plan, which clearly indicates the cost of the prescription and what was paid by the primary plan. Return the completed Prescription Drug Reimbursement/Coordination of Benefits Claim Form and receipt(s) to:

Express Scripts ATTN: Commercial Claims P.O. Box 2872 Clinton, IA 52733-2872 You may also fax your claim form to: 1 (608) 741-5475 For further information on Coordination of Benefits or for an explanation on the reimbursement of a claim, please call the Member Service at 1 (866) 544-1798.

Express Scripts Contact Information Express Scripts Member Services Express Scripts Member Services is available 24-hours a day, 7-days a week by calling toll-free 1 (866) 544-1798. Express Scripts’ Telecommunications Device (TDD) TDD assistance is available for hearing-impaired members by calling 1 (800) 759-1089. You can send Member Services a secure email through www.Express-Scripts.com. See the insert below on how to access the online inquiry page.


Other helpful toll-free phone numbers mentioned throughout this Benefits Booklet:

• Express Scripts’ Select Active Choice (Mail Order Opt-Out) Program: 1 (877) 603-1032

• Express Scripts’ Prior Authorizations Department:1 (800) 753-2851

• Express Scripts’ Prescription Form (Provider Only) Fax: 1 (800) 837-0959

• Express Scripts’ Prescriber Assistance: 1 (888) 327-9791

• Express Scripts’ Specialty Pharmacy, Accredo: 1 (800) 803-2523

• Express Scripts’ Specialty Pharmacy, Accredo (for Providers): 1 (800) 987-4904, option 5

• Express Scripts’ Specialty Pharmacy FAX, Accredo FAX: 1 (800) 391-9707

• Express Scripts’ self-service payment application (automated system only): 1 (800) 948-8779

The Frequently Asked Questions link is found on the bottom of the www.Express-Scripts.com Home Page after you log-on to your personal account. From the Frequently Asked Questions page, you can access the Help Center for several different accessibility resources and methods to contact Express Scripts Member Services. Member Services can also help connect you to language translation and interpreter service.


You can also learn more about your prescription benefits through the State of New Hampshire’s website at http://www.admin.state.nh.us/hr/health_benefits_active.html.

Other Things You Should Know

• Drugs and your safety The risks associated with drug-to-drug interactions and drug allergies can be very serious. Express Scripts will check for potential interactions and allergies, whether you use the Mail Order Program or the Retail Program. Express Scripts will also send this information electronically to participating retail pharmacies.

• Express Scripts may contact your doctor about your prescription

If you are prescribed a drug that is not on the preferred drug list but an alternative preferred drug exists, Express Scripts may contact your doctor to ask whether that drug would be appropriate for you. Please be assured that your doctor will always make the final decision on all your medications. If your doctor agrees to use a plan-preferred drug, you will generally save money.

• Express Scripts protects your privacy

Because your privacy is important, Express Scripts complies with federal privacy regulations. They use health and prescription information about you and your dependents only to administer the State of New Hampshire’s prescription drug plan and to fill your mail order prescriptions.


APPENDIX Frequently Asked Questions (FAQs) for the following topics: • Mail Order Pharmacy • Packaging and Shipping of Mail Order Medications • Worry-Free Fills • Generic Medications • Generic Step Therapy • Prior Authorizations • Controlled Substances

FAQs about Mail Order Pharmacy Q: How should my doctor write my home delivery prescription? A: To maximize your savings, ask your doctor to write your prescription for a 90-day supply with refills when appropriate instead of 30-day supply with refills. It is important to ask for a 90-day supply, as opposed to a 30-day supply, in order to receive up to 90 days of medication for one home delivery co-payment. Please note that you will be charged a home delivery co-payment regardless of the number of days' supply written on the prescription, so make sure your doctor has written the prescription for 90 days. Please note that the actual quantity and/or days' supply may vary for each drug. Your doctor's instructions on how to take the medication, state and federal dispensing guidelines, or how the medication is packaged may impact the quantity and/or days' supply you can receive. Q: How long does it take to get my medications when I use home delivery? A: First-time orders will usually be delivered within 8 to 11 days after Express Scripts receives your order. Refills usually arrive in less time. Refills ordered online are usually delivered within 3 to 5 days after Express Scripts receives your order. For refills mailed in, please allow 6-9 days. Renewals ordered online will usually be delivered in 5-8 days once Express Scripts receives your physician's approval of the renewal prescription. Mailed-in renewals will usually arrive in 7-11 days, once your order is received. New and renewal prescriptions faxed from your doctor will usually be delivered in 5-8 days. Please allow 24-48 hours for the prescription to appear online once your doctor has faxed in the prescription. The best time to reorder is when you have about a 14-day supply of your medication remaining. This will help ensure that you receive the medication you need, when you need it. Estimates for shipping may change if the order is processed differently than expected or if the delivery method is changed while the prescription is in process. The most up-to-date status is provided online as soon as it is available. Note: Certain medications, including many drugs prescribed for narcolepsy, attention deficit disorder, and pain management, are mailed via expedited delivery, and require a signature upon delivery. Q: How are medications shipped? A: Most medications are shipped via the U.S. Postal Service at no cost to you. Medications containing


certain controlled substances are shipped United Parcel Service (UPS). If necessary, you can request express shipping. Express shipping is also available for an additional fee. Q: What if I need to speak with a pharmacist? A: Express Scripts’ registered pharmacists are available 24 hours a day, seven days a week to answer any questions about your medications. Please call the toll-free number for Express Scripts Member Services at 1 (866) 544-1798. Q: How do I pay for my prescriptions? A: If you mailed your prescription to Express Scripts, you can enclose your payment with your order or you can be billed. If you used Express Scripts’ online services, you will be prompted for credit card information online or you can be billed. For your convenience, Express Scripts offers auto-charge, which allows you to place a credit card on file. When you enroll, Express Scripts will automatically charge any orders covered under your member number (all covered household members) to the card of your choice: American Express, Diner's Club, Discover® Network, MasterCard or Visa. To enroll, just call 1 (800) 948-8779, or select this option online when you place an order for a refill or renewal of a current prescription. Your credit card information is secured using the latest advances in commercially available security products. Q: When my doctor faxes you a prescription, what happens to it? A: When Express Scripts receives a faxed prescription from a doctor, they first make sure that the prescription is coming from a secure fax machine associated with a prescriber listed in their database. A secure fax machine is restricted from public access and is generally within a controlled area in the doctor's office. Express Scripts’ system automatically checks the incoming fax number against their database of recognized prescribers. If Express Scripts cannot determine the security of the fax line or if the incoming fax number cannot be matched against a prescriber in their database, then they contact the doctor's office to verify your prescription. Upon verification, the prescription information is entered into their system and processed. If they are unable to verify your prescription, they will attempt to contact you. If two attempts to contact you are unsuccessful, Express Scripts will send you a notification to inform you that they were unable to fill your prescription. Q: If I am going to be out of town for an extended time, how do I get an extra supply of drugs to cover me through that period? A: If you are going to be out of town for an extended period and need medication, call the toll-free number for Express Scripts Member Services at 1 (866) 544-1798 to request a vacation override once per calendar year. You must provide Express Scripts with the date you are leaving and when you plan to return. You may request up to a two (2) 31-day prescriptions in a retail pharmacy for double the applicable copayment amount. You may request up to a two (2) 90-day prescriptions via the Mail Order pharmacy for double the applicable copayment amount. In some cases, your provider may have to authorize the additional fill.

FAQs about Mail Order Packaging and Shipping Q: How can I identify a package that arrives from one of your pharmacies?


A: No matter how many packages or parcels you may receive, you can always feel confident knowing which are from the Express Scripts’ home delivery pharmacy. Just look in the upper left-hand corner of the shipping label to find the name MHS Services. Q: How will my medications be packaged? A: In most cases, Express Scripts uses heat- or glue-sealed plastic pouches, or "poly bags," to protect the prescription orders that they send from their pharmacies. This protective packaging enables them to fulfill their goal of delivering medications safely to members, and it has met the laboratory test standards set by the International Safe Transit Association. It works well with the automated packaging process used by the Express Scripts Pharmacy

SM.

When shipping your medications, Express Scripts may also use a gray plastic pouch, a brown or white corrugated box, a padded manila envelope, or an expedited carrier (for example, UPS). All of the packaging Express Scripts uses are "tamper evident," which will help members determine whether their order has been damaged or tampered with during delivery. Express Scripts’ "MHS Services" label appears on the side of each package. The label does not display the name "Express Scripts" or indicate that the package contains medications. This is done to protect your confidentiality and to reduce the possibility of theft. For prescription orders that are breakable, Express Scripts packages them by hand with bubble wrap and places them into corrugated boxes for maximum protection during delivery. Orders that are temperature sensitive require special packaging. Q: Why are my orders sometimes shipped in two or more packages? Is there a way to keep my orders in one package? A: When your medication order arrives in two or more packages, it is usually because Express Scripts has shipped it from different Express Scripts pharmacies. They split your medication order and fill it through different Express Scripts pharmacies for several reasons. For instance, a certain pharmacy may be able to provide one or more of your medications more quickly. Or your medications might be stocked at different Express Scripts pharmacies because of special requirements for those medications. (This is often the case with temperature-sensitive medications.) Also, not all Express Scripts pharmacies dispense controlled substances. Q: How will I know if my order has been shipped in more than one package? A: If your order has been shipped in more than one package, the invoice statement in each package will explain the situation. You will see a separate invoice number for each package within your order. Go to www.Express-Scripts.com to find out if your order has been divided into two or more shipments by clicking on "Prescription order status". Be assured that all of Express Scripts’ pharmacies maintain the same standard of excellence and are dedicated to dispensing your medications safely and quickly. Q: How do I change my shipping address? A: When ordering prescription medications, you may choose to receive your order at any address that Express Scripts has on file for you. Simply select the appropriate shipping address displayed from any of the addresses you have listed on your account during checkout. You can also request address changes by calling your toll-free member services number where a customer service representative would be happy to assist you with this change. NOTE: Please know that you are only changing the address where you will receive medications. You need to contact your benefits or payroll representative at the State of New Hampshire to change your address for your personnel, benefits and payroll records.


Q: I am getting a message that says you do not have an address on file for me. Why might this be? Is there a way I can change this? A: Mailing addresses initially received by Express Scripts are validated with a member's initial order. In some cases, the reason Express Scripts may not have a mailing address on file is because they may not have received complete mailing information when your benefit coverage began. Other times, you may not have placed an initial order with Express Scripts, which allows them to validate that address. Once an initial home delivery prescription order is placed, the address should remain on file until changed by the member. If Express Scripts does not have a record of an address on file, please contact Express Scripts Member Services at 1 (866) 544-1798 to rectify this situation. Q: What is your process for shipping temperature - sensitive medications? A: All drugs Express Scripts dispenses through the mail are reviewed for any unique shipping requirements, based on information from the manufacturer. In some instances, normal shipping procedures can be followed. For other items, Express Scripts will follow special shipping requirements if appropriate. When prescriptions for temperature-sensitive medications are processed, the medication will automatically be mailed to the patient via (overnight) shipping. Refills requested on Friday, Saturday or Sunday will be shipped on Monday. Most temperature-sensitive medications are shipped overnight or by 2nd-day air depending on the medication's sensitivity. These medications are shipped via a commercial shipping carrier to a street address that you provide. Please note that commercial carriers cannot deliver to a post office box. No signature is required, so you don't have to be home for delivery. Depending on the medication, a scheduling call may be made, in which case you should arrange to be home to receive the medication or to have it shipped to a relative, friend, or neighbor who will be home. If no scheduling call is needed, please be sure that these medications are retrieved and brought inside on the delivery day. Temperature-sensitive medications may also arrive in a separate package if ordered with other medications. Remember, if you ever have any questions regarding your prescription, an Express Scripts pharmacist is available to speak with you.

FAQs about Express Scripts Worry-Free Fills® Q: What is Worry-Free Fills? A: Worry-Free Fills gives you the peace of mind of knowing that your medication will be refilled and mailed to you automatically when your prescription is within 10 days of running out. There's no more worrying about ordering medications on time. Express Scripts will even send you an email approximately 2 weeks prior to the refill date to let you know that your refill is about to be processed. Q: How can I enroll a prescription in the Worry-Free Fills program? A: For each eligible prescription that you want to have automatically refilled, make sure there is a check mark in the box that says: "Automatically refill this prescription from now on with Worry-Free Fills" on the "Review your order" page. Express Scripts will automatically send you your next refill. You can also enroll your eligible prescriptions by calling your toll-free Member Services phone number. Please note that certain medications are not eligible for Worry-Free Fills. The Worry-Free Fills option is not displayed if the medication is not eligible.


Q: How can I remove a prescription from or turn off the Worry-Free Fills program? A: You may remove a prescription from the Worry-Free Fills program at any time without cancelling the current order by visiting the "Order Status" page or "Worry-Free Fills" page and clicking on the "Turn off Worry-Free Fills for this Prescription" link next to the medication you want to remove from Worry-Free Fills or call your toll-free Member Services phone number. Removing a prescription from the Worry-Free Fills program will not cancel the pending order. However, you will need to order any subsequent refills online, call 1 (866) 544-1798, or mail in a refill slip with an order form. Q: How can I cancel a pending prescription order if it is enrolled in the Worry-Free Fills program? A: You may cancel a pending prescription that is enrolled in the Worry-Free Fills program up to 48 hours before your medication is processed by visiting the "Order Status" page or "Worry-Free Fills" page and clicking on the "Cancel Prescription" link. Or you may call your toll-free Member Services phone number. If you choose to cancel a prescription that is enrolled in the Worry-Free Fills program, you will no longer receive automatic refill shipments, even if you have refills remaining. You will need to go to the "Order Center" page online to place a future order for any remaining refills, call 1 (866) 544-1798, or mail in a refill slip with an order form. Q: Why are some of my medications already checked off for Worry-Free Fills? A: Express Scripts may have pre-selected your eligible generic medications for enrollment in this program to highlight for you the convenience of automatic refills, while taking advantage of the potential lower costs offered by generics. You can choose to enroll other eligible medications to take further advantage of the convenience of Worry-Free Fills. Or, if you prefer not to receive automatic refills, you can turn off Worry-Free Fills for these medications at any time. Q: Are all my prescriptions eligible for Worry-Free Fills? A: A prescription is eligible for the Worry-Free Fills program if: 1) it is dispensed by the home delivery Express Scripts Pharmacy

SM, 2) you have taken the medication for a minimum of 30 days, 3) the

prescription will not expire before your next refill and 4) it is for at least a 56 day supply. Certain drugs, such as controlled substances, over-the-counter medications, and specialty drugs, are not eligible for the Worry-Free Fills program. Q: What happens when my current prescription runs out and I have no more refills? A: As part of the services of the Worry-Free Fills program, the Express Scripts Pharmacy will contact your doctor when you are out of refills for your medication. Once Express Scripts receives your new prescription, you will continue to receive the prescribed number of refills automatically. With Worry-Free Fills, you will receive your medication when your refill is due. There is nothing you need to do. Express Scripts will automatically ship your eligible medications when you're within 10 days of running out. Q: How can I change my medication ship date? A: You can change your medication ship date by visiting the "Order Status" page and clicking on the "Change date" link. Note that you should only extend your ship date if you think you already have enough medication on hand. Q: When will I be billed for the automatic refills?


A: You will not be billed until after your medication has been dispensed. Q: How can I remove the Worry-Free Fills check mark off my medication? A: You can remove the Worry-Free Fills check mark off a medication by simply clicking on the box next to "Automatically refill this prescription from now on with Worry-Free Fills". Q: Why should I enroll my future prescriptions for Worry-Free Fills? A: You have the option to enroll in the Worry-Free Fills program by individual prescription or for all your current and future eligible prescriptions. If you enroll your eligible future prescriptions in Worry-Free Fills®, your refill process will be one step shorter. When you enroll your future prescriptions, every new prescription eligible for Worry-Free Fills will automatically be sent to you when it's time to refill. You won't have to remember to select the Worry-Free Fills option for your enrolled prescriptions in the future. If an enrolled prescription needs to be renewed, Express Scripts will automatically contact your prescriber to authorize the renewal. Status and pricing information for future prescriptions you enroll will still appear in the Worry-Free Fills Center. You will also continue to receive a notice prior to shipment of your orders, and you will still have the option to change the shipping date or cancel any order, either on Express-Scripts.com or by calling customer service. Q: Will enrolling all my future prescriptions in Worry-Free Fills also enroll my current prescriptions? A: No; enrolling all future prescriptions automatically includes all eligible future prescriptions in Worry-Free Fills but does not enroll your current prescriptions. Your current prescriptions will need to be enrolled in Worry-Free Fills individually in either the Order Center or Worry-Free Fills Center.

FAQs about Generic Medications Q: What is a generic version of a brand-name drug? A: A generic version (or equivalent) is a medication that is generally sold under the name of its active ingredients—the chemicals that make it work—rather than under a brand-name, and it is typically much less expensive than its brand counterpart. Generic versions that have been approved by the U.S. Food and Drug Administration, or the FDA, contain the same active ingredients—and are the same in safety, strength, performance, quality, and dosage form—as their brand counterparts. Q: Does every brand-name drug have a generic version? A: Not every brand-name drug has a generic version that is available to the public. Generic versions generally become available for sale only after the patent for the brand has expired. Once the patent expires, other manufacturers can produce and sell generic versions. Q: When does a generic version become available? A: Drug manufacturers can market a generic version after the patent for the brand-name drug has expired and the generic version has been approved by the FDA. Generally, patents expire 20 years after they are initially filed, but by the time the brand-name drug has completed testing and is approved for sale, as few as 10 years may remain on the patent. Q: Why do generic drugs cost less than brand-name drugs? A: A generic drug typically costs less to develop because its manufacturer does not have to perform all


the costly clinical studies that the manufacturer of the brand had to perform during development. In developing a generic version, the manufacturer can use the clinical data that has been gathered about the brand-name drug's safety and effectiveness. Generic manufacturers also don't spend money advertising their drugs in magazines and on TV. So, generic drugs are less expensive for you and your health plan. Q: I understand that I can avoid higher costs by using generic drugs, but am I giving up quality? A: No, not at all. The FDA reviews approved generic drugs to ensure that they match their brand counterparts in safety, quality, strength, and dosage.

FAQs about Generic Step Therapy

Q: Who decides what drugs are covered in step therapy? A: In accordance with the State’s pharmacy plan design, step therapy is developed under the guidance and direction of independent, licensed doctors, pharmacists and other medical experts. Together with Express Scripts they review the most current research on thousands of drugs tested and approved by the FDA for safety and effectiveness and recommend appropriate prescription drugs for step therapy under your plan. Q: How do I know what front-line drug my doctor should prescribe? A: Only your doctor can make that decision. You can go to Express-Scripts.com (located under Manage Prescriptions / Price a Medication) for a list of your plan’s front-line drugs. For additional information about Express Scripts’ formulary drugs that require generic step therapy, go to www.Express-Scripts.com, under the ‘Manage Prescriptions’ menu, select the ‘Price a Medication’ link or call Express Scripts toll-free at 1 (866) 544-1798. Q: What if I need a prescription filled immediately at a retail pharmacy and I do not want to go through the Step Therapy process? A: If your provider wants you to take a certain medication without trying a generic or front-line medication first, they may do so through the prior authorization or override process. Until that prior authorization is approved by Express Scripts, your pharmacist may tell you that your prescription is not covered. If this occurs and you need your medication quickly, you can:

a) Talk with your pharmacist about filling a partial supply of your prescription right away. You may have to pay full price for this prescription based on the retail pharmacy’s policy. If you paid full price and prior authorization is subsequently granted, you can go back to the pharmacy and request a refund of the price you paid minus the applicable copayment or ask to have your claim reprocessed.

b) Then, ask your pharmacist to contact your doctor. Your doctor needs to call the Express

Scripts Prior Authorization Department at (800) 753-2851 to find out if this drug can be covered by your plan. Only your doctor (or in some cases, your pharmacist) can provide the information needed to make this determination. If the prior authorization is approved, you’ll pay the appropriate copayment for this drug. If it is not approved, you will either have to pay full price for the back-up drug or take an alternative.

Q: What if I can’t use the less expensive (front-line) drug?


A: With step therapy, more expensive brand-name drugs are usually covered as a back-up in the program if:

• You’ve already tried the generic drugs covered in your step therapy program • You can’t take a generic drug (for example, because of an allergy) • Your doctor decides, for medical reasons, that you need a brand-name drug

If one of these situations applies to you, your doctor can request an override or a “prior authorization” for you, allowing you to take a back-up prescription drug. Once the override is approved, you’ll pay the appropriate copayment for this drug. If the override isn’t approved, you will either have to pay full price for the back-up drug or take an alternative. Q: What are generic drugs? A: Generic equivalent medications have the same chemical makeup and same effect in the body as their original brand-name counterparts. Though generics may have a different name, color, and/or shape, generics have undergone rigorous clinical testing and been approved by the U.S. Food & Drug Administration (FDA) as safe and effective. Unlike manufacturers of brand-name drugs, the companies that make generic drugs don’t need to spend as much money on research and advertising. As a result, generic drugs cost less than the original brand-name drug, and the savings get passed on to you. Q: I sent in a prescription to home delivery and was told I need to use a front-line drug. What happens now? A: Step therapy applies to prescriptions you receive at your local pharmacy, as well as those you order through home delivery, so the same basic process applies. Your doctor may write a prescription for a front-line drug covered by your plan, or your doctor can request an override or a “prior authorization” for you. FAQs about Prior Authorizations Q: Who decides what prescription drugs require prior authorization? A: The prior authorization program was developed under the guidance and direction of independent licensed doctors, pharmacists and other medical experts. Together with Express Scripts these experts review the most current research on thousands of prescription drugs tested and approved by the FDA as safe and effective and recommend prescription drugs that are appropriate for prior authorization under your plan. Q: What kinds of prescription drugs need a prior authorization in my program? A: Your prior authorization program applies to prescription drugs that:

• have dangerous side effects or can be harmful when combined with other drugs • should be used only for certain health conditions • are often misused or abused • are prescribed when less expensive drugs might work better

For additional information about Express Scripts’ formulary drugs that require prior authorization, go to www.Express-Scripts.com, under the ‘Manage Prescriptions’ menu, select the ‘Price a Medication’ link or call Express Scripts toll-free at 1 (866) 544-1798.

Q: Why couldn’t I get my original prescription filled at the pharmacy? A: When a prescription needs a prior authorization:


1. Your pharmacist sees a note on the computer system indicating “prior authorization required.” 2. Express Scripts or your pharmacist lets you know that your prescription needs a prior

authorization – which simply means that more information is needed to determine if your plan can cover the medication.

3. You can ask your doctor to call Express Scripts for prior authorization. Only your doctor (or in some cases, your pharmacist) can give Express Scripts the information needed to see if your medication can be covered. The prior authorization phone lines are open 24 hours a day, 7 days a week, so a determination can be made right away. If you learn your prescription requires a prior authorization, you can ask your doctor if there is a different medication you can use that’s covered by your plan. If your doctor does not wish to complete the requirements of the prior authorization program, you have the option of paying the full price for the prescription at your pharmacy. (Note: You will not be reimbursed if you choose this option and the amount you pay will not be applied to your out of pocket maximum).

4. If your doctor (or pharmacist) calls for a prior authorization, an Express Scripts licensed

pharmacist will: • Check your plan’s guidelines to see if your prescription can be covered, and • Determine whether your plan will cover the medication only when it’s used for treating

specific FDA approved medical conditions, rather than for other purposes.

Your doctor or pharmacist will be asked questions about your specific condition. If the information provided meets your plan’s requirements, prior authorization will be granted and you will be responsible for paying the applicable copayment at the pharmacy.

Q: I need a prescription filled immediately at a retail pharmacy. What can I do? A: At the pharmacy, your pharmacist may tell you that your prescription requires prior authorization. If this occurs and you need your medication quickly, you can:




Q: Does this program deny me the medication I need? A: No, the program can help you get an effective medication to treat your condition. Through prior authorization, you can receive the right prescription for you that is covered by your benefits. If it’s determined that your plan doesn’t cover the original medication you were prescribed, you can ask your doctor about getting a different medication that is covered. Covered medications will be subject to the applicable copayment. Or, you can choose to fill the original prescription at your pharmacy by paying the full price. Q: What happens if my doctor’s request for prior authorization is denied?


A: Your prescription benefit doesn’t cover certain medications. If you want to file an appeal to have your prescription covered, contact Express Scripts Member Services at 1 (866) 544-1798. Q: I filed an appeal and it was denied. What can I do? A: There are two things you can do:

1. You can talk with your doctor again about prescribing a different medication that is covered by your plan, or

2. You can pay the full price for a medication that isn’t covered by your plan.

Q: I sent a prescription to Express Scripts home delivery pharmacy services, but I was told it needs a prior authorization. What happens now? A: Express Scripts home delivery pharmacy services will try to contact your doctor. You may want to let your doctor know that this call will be coming. If your doctor thinks you need this prescription for your condition, he/she can talk with an Express Scripts home delivery pharmacy services representative about a prior authorization.

FAQs about Controlled Substances

Q: What is a controlled substance or controlled medication?

A: The federal government has categorized a class of medication as having a higher-than-average potential for abuse or addiction. Such medications, known as controlled substances, are divided into categories based on their potential for abuse or addiction. They range from illegal street drugs (Schedule 1, or C1) to medications with decreasing potential for abuse (C2 through C5). Prescriptions containing narcotics or amphetamines are often classified as C2, since they have a relatively high potential for abuse or addiction.

Q: Are there any drugs prohibited from mailing? If so, which ones? A. There are some specific categories of medications that cannot be mailed or may require specific delivery restrictions. Some medications, such as pain relief or sleep agents, are not classified as maintenance (although they may be for your treatment). You can continue filling these types of prescriptions at your local retail pharmacy. If you have specific questions about your medication, you can call Express Scripts Member Services at 1 (866) 544-1798. Q. Can I receive medications that are classified as “controlled substances” through the mail order?

A. You can obtain many controlled substances through the mail order; however, some do require signature upon delivery. Some may also require a new prescription for each fill and have dispensing restrictions that would only allow a certain day supply vs. a 90-day supply. Examples of controlled medications are pain relief and sleep agents. Check with your doctor if you are taking a controlled substance to determine if there are any restrictions and if it would be appropriate for you to fill through the mail order. However, it is important to note that you can continue filling most controlled substances for up to a 31-day supply at the retail pharmacy; you are not required to use mail order when filling these types of prescriptions.

Q: Do controlled substances have special prescribing and dispensing requirements?


A: Yes. Most prescriptions for controlled substances are subject to both federal and state regulations. These regulations define how a prescription can be written, how your doctor can communicate it to a pharmacist, and how many times it can be refilled, among other aspects. For example, many controlled substances can only be refilled up to 6 months from the date of the original prescription, and medications with a higher potential for abuse (C2) cannot be refilled at all. All pharmacies, whether retail or home delivery, are subject to these regulations.

For more information about controlled substances and New Hampshire regulations regarding them, please contact your provider or Express Scripts Member Services at 1 (866) 544-1798.


Prescription Drug Benefit Program

Express Scripts Pharmacy

Home Delivery Service

It is the objective of the State of New Hampshire Employee and Retiree Health Benefit Program to maintain the high quality

health coverage you expect while managing this valuable benefit’s cost. The Prescription Drug Benefit Program provides

savings for the State Health Benefit Program and flexibility for members by offering programs like the Express Scripts

Pharmacy Home Delivery Service.

The State encourages you to use mail order to fill your long-term or maintenance prescriptions when appropriate. The

mail order program offers significant cost savings to both you and the State Health Benefit Program.

The State will continue to offer the mail order opt-out program through Express Scripts called the Home Delivery Select

Active Choice Program (Opt-Out Program). The Opt-Out Program is designed to support individual situations where mail

order requirements create an unanticipated and unique hardship. Further details are described below.

What You Should Know:

• If you currently use mail order for your maintenance medications and enjoy its cost savings and convenience, you

may continue to do so under Express Scripts. Do not forget to register online for your new Express Scripts

account on or after January 1, 2014 at www.Express-Scripts.com or call Express Scripts at (866) 544-1798 to

provide your payment information and set up the Worry-Free Fills auto-refill service.

• The Prescription Drug Benefit Program provides you with the choice of filling your maintenance or long-term

prescriptions through the Express Scripts Pharmacy Home Delivery Service or at a retail pharmacy location.

• If you have not opted out in the past and you fill a new maintenance or long term medication at a retail pharmacy,

you will be contacted by Express Scripts via phone and mail reminding you to send your prescription to the Express

Scripts Pharmacy Home Delivery Service for refills.

o You may receive up to three retail pharmacy refills of the same maintenance medication.

o On the fourth retail refill, if you have not opted-out of mail order, you will be responsible for the full payment of

the prescription.

• The Opt-Out Program is designed to provide more flexibility in those situations where mail order requirements create

an unanticipated or unique hardship on some individuals.

• If you elect to opt-out of the Express Scripts Pharmacy Home Delivery Service, you may only receive up to a 31-

day supply at a retail pharmacy. You will also be subject to the plan’s retail copayment.

• Mail order will continue to be an available option, even if you elect to opt-out.

• The opt-out feature will not apply for specialty medications; these are provided by Accredo Health Group, Inc., an

Express Scripts specialty pharmacy.

• You can learn more about your benefits through the State’s website:

http://admin.state.nh.us/hr/open_enrollment_active.html or http://admin.state.nh.us/hr/retirement_benefits.html.

How To Opt-Out of Express Scripts Pharmacy Home Delivery Service:

• If the mail order program has caused an unanticipated and unique hardship for you or your family members and you

feel it is in your or their best interest to opt-out of the mail order pharmacy program, call the Express Scripts Home

Delivery Select Active Choice toll free number at (877) 603-1032 on or after January 1, 2014.

o If you previously opted-out of mail order, your opt-out status should transfer to Express Scripts. You can call

Member Services to confirm your election at (866) 544-1798.

o Spouses and dependent children age 18 and older should call separately to opt-out.

o Your request to opt-out will take effect immediately for all of your long-term or maintenance prescriptions,

including newly prescribed ones.

• Cancel your automatic refills or renewals at www.Express-Scripts.com or at the time of your opt-out call if you do not

want them to continue.

• Obtain new prescriptions for medications you currently fill through mail order but wish to fill at a local retail

pharmacy.

State of New Hampshire Retiree Health Benefit Program

Non-Medicare Eligible Retiree

Prescription Drug Benefits Booklet

Disclaimer: This document summarizes pharmacy benefit options offered by the State of New Hampshire

through Express Scripts. It is not a complete statement of the terms and conditions under which benefits

are available. This booklet is intended to describe benefits that are offered as accurately as possible.

Benefits are set forth in and governed by all applicable coverage documents. In the event of any

discrepancy between this booklet and the actual terms and conditions of those documents, the

documents will govern.

January 2017



Table of Contents Your Pharmacy Benefit at a Glance .......................................................................................................... 5

2017 Copayments for Non-Medicare Eligible Retirees: ......................................................................... 5

Use of Generic Medications ................................................................................................................... 6

Maintenance Medications through Mail Order ....................................................................................... 6

Specialty Medications ............................................................................................................................ 6

Manage Your Pharmacy Benefits Online............................................................................................... 6

Understanding Your Pharmacy Benefits................................................................................................ 8

Who is Eligible for the Pharmacy Benefit Plan ...................................................................................... 8

What is Covered Under Your Pharmacy Plan ....................................................................................... 8

What is Not Covered .............................................................................................................................. 9

Express Scripts’ Preferred Drug List Exclusions ................................................................................... 9

Express Scripts’ Compound Management Solution .............................................................................. 9

Your Pharmacy Options .......................................................................................................................... 10

Mail Order Program: Express Scripts Pharmacy Home Delivery Service ........................................... 10

Mail Order Opt-Out Program ............................................................................................................... 12

Worry-Free Fills ................................................................................................................................... 12

Retail Pharmacy Program .................................................................................................................... 14

Express Scripts Specialty Pharmacy Program .................................................................................... 14

Other Important Pharmacy Program Information .................................................................................... 15

The Generic Drug Advantage .............................................................................................................. 15

Medications Preferred By Your Plan Design ....................................................................................... 15

Generic Step Therapy .......................................................................................................................... 16

Prior Authorization Requirements ........................................................................................................ 17

Quantity Limits ..................................................................................................................................... 18

Coverage of Preventive Medications ................................................................................................... 19

Appeal Administration .......................................................................................................................... 20

Coordination of Benefits ...................................................................................................................... 24

Express Scripts Contact Information ................................................................................................... 25

Other Things You Should Know .......................................................................................................... 27

APPENDIX............................................................................................................................................... 28

FAQs about Mail Order Pharmacy ....................................................................................................... 28

FAQs about Mail Order Packaging and Shipping ................................................................................ 29

FAQs about Express Scripts Worry-Free Fills® .................................................................................. 31

FAQs about Generic Medications ........................................................................................................ 33

FAQs about Generic Step Therapy ..................................................................................................... 34

FAQs about Prior Authorizations ......................................................................................................... 35

FAQs about Controlled Substances .................................................................................................... 37



Your Pharmacy Benefit at a Glance Express Scripts administers the State of New Hampshire’s retiree prescription drug benefits.

This plan is subject to a “drug list” or “formulary”. This is a list of prescription drugs that are preferred by Express Scripts because of their safety, clinical effectiveness and ability to help control prescription drug costs. The drug list is updated on a regular basis and can be found online at www.Express-Scripts.com. You may also request a copy by calling Express Scripts Member Services at (866) 544-1798.

This plan is not subject to a pharmacy deductible and does not have co-insurance.

You are responsible for paying the applicable copayment for each prescription as listed on the Express Scripts drug list. Copayments are the amount paid by you for each prescription, or authorized refill. The copayments for each category provided below are based on a single prescription, or refill.

Annual Out-of-Pocket Maximums are the total copayments you, or your family, are required to pay in a calendar year. Once this amount is reached, the State will pay 100 percent of the cost of your medications through the remainder of the calendar year. The accumulated copayment amounts are reset to zero at the beginning of each calendar year.

Each prescription shall not exceed the days’ supply limits listed below and is based on the prescriber’s dosage and quantity indicated on the prescription:

o Ninety (90) day supply for the Mail Order Program called the Express Scripts PharmacySM Home Delivery Service,

o Thirty-one (31) day supply for the Retail Pharmacy Program.

o The days’ supply limit is subject to exceptions for the following:

- Certain pre-packaged drugs with greater than a 31-day supply which may require multiple copayments,

- Certain medications, like controlled substances, that have quantity limits on the amount dispensed as defined by federal regulations.

All prescriptions have a maximum number of refills as specified by the prescriber and must be renewed at least every 12 months.

2017 Copayments for Non-Medicare Eligible Retirees: Retail Pharmacy Program Generic Drugs $10 copayment Preferred Brand-Name Drugs $25 copayment Non-preferred Brand-Name Drugs $40 copayment Certain Preventive Medications $0 copayment Mail Order Program Generic Drugs $10 copayment Preferred Brand-Name Drugs $50 copayment Non-preferred Brand-Name Drugs $80 copayment Certain Preventive Medications $0 copayment Annual Out-of-Pocket Maximum Individual $750 per person per calendar year

Family $1,500 per family per calendar year

http://www.express-scripts.com/


Use of Generic Medications Your pharmacy plan requires that you use a generic medication when available. When a generic equivalent is available but the pharmacy dispenses the brand-name medication for any reason other than a doctor’s “dispense as written” (DAW) orders or similar instructions, you will pay the generic copayment plus the difference in full cost between the brand-name and the generic. The difference in payment will not count toward your annual out-of-pocket maximum. When your doctor recommends the brand-name for treatment and includes the necessary instructions, you will pay the brand-name copayment as indicated above. (Also see the Generic Step Therapy section in this document for more information about using generic medications before requesting the brand name.) Exception: If a generic medication is out of stock at the time a prescription is requested, Express Scripts may substitute the generic with a preferred brand, if it is available. The copayment will coincide with the original prescription requested.

Maintenance Medications through Mail Order Your plan requires that maintenance or long-term medications be filled through the Express Scripts Pharmacy


before you are charged the full price of the medication. Express Scripts will reach out to you by phone and by mail before you are charged the full price of the medication. (See the sections in this document on the Mail Order Program, the Retail Pharmacy Program, and the Mail Order Opt-Out Program for more information about your options to receiving your medications.)

Specialty Medications Specialty medications must be filled through Accredo, the full-service Express Scripts specialty pharmacy. (See the Express Scripts Specialty Pharmacy Program section in this document for more information about your specialty pharmaceutical benefits.)

o For specialty prescriptions that must be filled more frequently or for a 31-day supply or

less, you will be charged the retail copayment for each supply.

o If your specialty prescription can be filled every 90 days, or more than a 31-day supply, you will be charged the mail order copayment for each supply.

Manage Your Pharmacy Benefits Online Although not required, you are encouraged to register for your own Express-Scripts.com online account as the website is referenced throughout this Benefit Booklet. To register, visit www.Express-Scripts.com and click on the “Register Now” orange icon on the home page. You will need your Express Scripts Member ID Card to register. You will fill out a brief registration form to ensure the security and privacy of your account. You will also be prompted to create a username and password (choose ones you will remember for logging on in the future). Once you have reviewed all the information you have entered and made any necessary changes, you will need to read and accept the Express Scripts terms and conditions. It may be helpful to have a current prescription on hand when registering. Once online, you will have access to tools and resources that allow you to:

Request mail order refills

Learn about medications and interactions

Compare brand-name and generic drug prices

http://www.caremark.com/


Check the status of mail orders

Check and pay mail order account balances

Locate a participating retail pharmacy

Review benefit plan highlights

Obtain order forms and claim forms

Request temporary Member ID cards The home page of the Express Scripts website is designed to be a quick-access dashboard for your prescriptions. Under the Express Scripts logo at the top of the home page you will find several drop down menus that appear when you hover your mouse pointer over the words ‘Manage Prescriptions’, ‘Health & Benefits Information’, and ‘My Account’. You will also find quick links at the bottom of the home page (see insert below). Frequently Asked Questions (circled below) is where you will find answers to several topics including how to send a secure message to Express Scripts via the web. You are encouraged to explore the website for valuable resources available to you and your family.

Under the ‘My Account’ menu at the top of the Home page, choose the ‘Select Communication Preferences’ option. At the bottom of the screen under the ‘Your Preferences’ section of the page, click on the ‘Communication preferences’ link. Click on the ‘Edit preferences’ link in the top right hand corner of the ‘Viewing preferences’ window and the ‘Communication preferences’ window. In this window (depicted below), you may choose to include the name of the medications, patient names and full prescription numbers in email communications with Express Scripts.


Understanding Your Pharmacy Benefits It is recommended that you understand how your prescription benefits work and how your requests to fill prescriptions will be processed by Express Scripts. The ‘Price a Medication’ tool at www.Express-Scripts.com (found under the Manage Prescriptions drop down menu) provides the following information once you enter the name and dosage of the prescription you wish to fill:

• The copayment amount you will be charged;

• If a generic equivalent or lower cost alternative is available;

• If there are special requirements that must be met before a prescription can be filled: o If a prior authorization or medical review is required from your doctor; o If you are required to try the generic first (generic step therapy); or o If there are quantity limits on the amount of medication that can be dispensed.

You may also request this information by calling Express Scripts Member Services at (866) 544-1798.

Who is Eligible for the Pharmacy Benefit Plan Eligibility for coverage under the State of New Hampshire pharmacy benefits is determined by the eligibility criteria set forth in the medical plan benefit book. Your enrollment in the plan is dependent on your enrollment election in the medical benefits. There are no separate enrollment forms to elect the pharmacy benefit.

What is Covered Under Your Pharmacy Plan Covered drugs which, under New Hampshire or federal law, require a prescription and are designated as part of the plan design outlined below. Excluded from covered drugs are: (i) cosmetic drugs; (ii) appliances, devices, bandages, heat lamps, braces, splints, and artificial appliances; and (iii) health and beauty aids, cosmetics, and dietary supplements, unless otherwise required by New Hampshire or federal law, and is a prescription drug provided through Express Scripts. All State of New Hampshire plan design options cover the following:

State regulated drugs

Diabetes supplies, including insulin syringes

Insulin by prescription only

Federal legend drugs, including: - Cardiovascular drugs - Anti-infectives - Dermatological therapies

- Ear, nose, and throat medications - Ophthalmology drugs - Respiratory, allergy, cough, and cold medications - Oral diabetes drugs - Growth hormones and injectables - Contraceptives and devices

Emergency contraception medications (prescription and OTC)

Immunizing agents

Tobacco cessation medications, including over-the-counter products Certain controlled substances, and other prescribed medications, may be subject to dispensing limitations and to the professional judgment of the pharmacist. Prescriptions for certain controlled substances may be shipped under separate cover. (See the section on Drug Quantity Limits for more information.) Under the Affordable Care Act (ACA), commonly known as health care reform, certain preventive medications, including over-the-counter (OTC) medications, are covered without charging a copayment, coinsurance or deductible (zero-dollar cost share). The State of New Hampshire Prescription Benefit




Program, in consultation with Express Scripts, has developed a list of medications and criteria (i.e., gender and age) to support preventive medication requirements based on the recommendations of the U.S. Preventive Services Task Force (USPSTF) and the Centers for Disease Control and Prevention (CDC) to be covered under the pharmacy benefit. If you meet the eligibility criteria for the zero-dollar cost share, Express Scripts will automatically waive your copayment based on the medication being prescribed, specific to age and gender requirements of the ACA for covered retirees and their dependents. All medications will require a prescription, including over-the-counter medication. (See the section on ACA Preventive Medications for more information.)

What is Not Covered All plan design options exclude coverage for the following:

Therapeutic devices or appliances;

Anti-Obesity medications;

Non–federal legend drugs, except insulin;

Drugs labeled “Caution—Limited by Federal Law to Investigational Use,” or experimental drugs, regardless of whether a charge is made to the member;

Medication for which the cost is recoverable under any workers’ compensation or occupational disease law or any state or government agency, or medication furnished by any other pharmaceutical or medical service for which no charge is made to the member;

Medication taken or administered to the member while he or she is a patient in a licensed hospital, rest home, sanitarium, extended care facility, skilled nursing facility, convalescent hospital, nursing home, or similar institution that operates on its premises, or allows to be operated on its premises, a facility for dispensing pharmaceuticals;

Any prescription that has reached the maximum number of refills specified by the physician, or any prescription that is more than one year old.

Express Scripts’ Preferred Drug List Exclusions Express Scripts has a list of medications that are not included on the Drug List. This list of drugs is called the Preferred Drug List Exclusions and can be found on www.Express-Scripts.com. (The list is located on the bottom of the home page in the Benefit & Account Notifications box.) These drugs are not covered due to their high cost and the availability of lower cost medications that are equal in clinical effectiveness. If you choose to fill this medication, you are subject to the full cost of the drug and the cost will not count toward your Annual Out-of-Pocket Maximum. Express Scripts recognizes that some physicians may still want to prescribe the medications on the Preferred Drug List Exclusions and may do so through the Prior Authorization process.

Express Scripts’ Compound Management Solution Certain compounded medications are excluded from coverage under the Plan. The Express Scripts’ Compound Management Solution uses the following criteria to determine medical necessity and if the compounded ingredients are covered:

Availability of commercially alternative medications (FDA approved prescription);

Availability of an over-the-counter (OTC) alternative product;

Clinical evidence of safety and efficacy of the compounded ingredient(s); and

Whether an ingredient represents a significant cost or has significant and/or continuous price increases.

Express Scripts recognizes that some physicians may still wish to prescribe a compounded medication that includes one or more excluded ingredients. The prescriber should contact the Express Scripts’ Prescriber Assistance Department at 1 (888) 327-9791 for more information.



Your Pharmacy Options

Mail Order Program: Express Scripts Pharmacy Home Delivery Service Your plan requires that maintenance or long-term medications be filled through the Express Scripts Pharmacy


before you are charged the full price of the medication. Express Scripts will reach out to you by phone and by mail before you are charged the full price of the medication. All enrollees are offered the option of having their maintenance or long-term medications (those taken for 3 months or more) delivered to their home or other location. Medications are dispensed by the Express Scripts Pharmacy pharmacists through its network of mail order pharmacies. Mail Order Program Basics

You may obtain up to a 90-day supply (compared with a typical 31-day supply at retail) of each covered medication for one mail order copayment. Registered pharmacists are available 24 hours a day, 7 days a week.

Express Scripts Home Delivery mail order pharmacies will not be required to dispense prescriptions for greater than a 90-day supply of covered drugs per prescription or refill, subject to the professional judgment of the dispensing pharmacist, limitations imposed on controlled substances, and the manufacturer’s recommendations. Prescriptions may be refilled provided it is stated in the prescription.

Order refills online, by mail, or by phone—anytime day or night. To order online, register at www.Express-Scripts.com. Refills are usually delivered within 8 days after your request is received in good order.

A “request in good order” is a prescription that has all the proper medical authorizations in place and, based on the prescriber’s instructions, the remaining supply on hand from the previous refill has depleted to approximately 25% or two (2) weeks to ten (10) days.

Payment Options— When using home delivery, you can pay by check, e-check (see below for additional information), money order or credit card. If you prefer to use a credit card, you have the option of joining Express Scripts’ automatic payment program by calling the self-service payment application at (800) 948-8779 or by enrolling online. If you prefer to speak to a live customer service representative, call 1 (866) 544-1798. Credit cards accepted include Visa, MasterCard, Discover, American Express, and Health Reimbursement (HRA) or Flexible Spending Account (FSA) debit cards.


Standard shipping is free.

When it is time for you to renew your prescription (usually after one year), you can choose to obtain a new prescription from your doctor directly or request that Express Scripts reach out to your doctor for you by calling Express Scripts Member Services at 1 (866) 544-1798.

How to initiate the Mail Order Program There are several ways to initiate the use of mail order for your maintenance medications. The online method is the fastest and easiest way to initiate the mail order program. Online:



Ask your doctor to write a prescription for up to a 31-day supply with enough refills for twelve (12) months and fill it immediately at your chosen local pharmacy.

After you’ve filled your 31-day prescription, go to www.Express-Scripts.com. o It may take up to 48 hours for your medication to appear on your home page. o From your home page at Express-Scripts.com, scroll down to the Prescriptions section.

You will find a purple box entitled “Transfer to Home Delivery” under the prescription you filled at the retail pharmacy. Follow the directions on the page to initiate the transfer to mail order.

By mail:

If you prefer to mail your written prescriptions directly to Express Scripts, you may do so by asking your doctor to write a prescription for up to a 90-day supply of each medication (plus refills for up to 1 year, if appropriate).

If you are currently taking a medication, be sure to have at least a 14-day supply on hand when ordering. If you do not have enough, ask your doctor to give you a second prescription for up to a 31-day supply to fill at a participating retail pharmacy while your mail order prescription is being processed.

You will need to include a completed Express Scripts Home Delivery mail order form with your written prescription.

o Express Scripts Home Delivery mail order forms can be found at www.Express-Scripts.com. They are available for printing under the Health & Benefits Information menu. Select ‘Print & Request Forms & Cards’ from the drop down menu.

o You may also call Express Scripts Customer Service at (866) 544-1798 to request mail order forms be mailed to you.

Mail your prescriptions and completed mail order form(s) to the address listed on the mail order form. Appropriate US postage will be required.

To help avoid delays in filling your prescription, be sure to include payment with your order. Payment options are listed on the mail order form.

By phone:

If you prefer to order your mail order prescriptions by phone, you can request that Express Scripts contact your doctor directly to submit a prescription to the Mail Order Program on your behalf by calling (866) 544-1798.

If you are currently taking a medication, be sure to have at least a 14-day supply on hand when ordering. If you do not have enough, ask your doctor to call in a second prescription for up to a 31-day supply to fill at a participating retail pharmacy while your mail order prescription is being processed.

Be sure to have your identification number located on your Express Scripts prescription card, doctor’s name and medication name available at the time of your call.

By fax from your doctor:

You may also have your doctor fax your prescriptions. Ask your doctor to call the Express Scripts Prescriber Assistance Line at 1 (888) 327-9791 for faxing instructions.

Or you may print a mail order fax form for your physician to complete. The fax forms can be found at www.Express-Scripts.com under the Health & Benefits Information menu. Select ‘Print & Request Forms & Cards’ from the drop down menu.

If you are currently taking a medication, be sure to have at least a 14-day supply on hand when ordering. If you do not have enough, ask your doctor to give you a second prescription for up to a 31-day supply to fill at a participating retail pharmacy while your mail order prescription is being processed.

Note: Faxes must be sent from your doctor’s office. Faxes from other locations, such as your home or workplace, cannot be accepted.

You can expect new prescriptions to arrive 7-10 calendar days after Express Scripts receives your order. Refills are usually delivered within 8 days following Express Scripts’ receipt of your refill





request. Your medication will be mailed to your home via standard U.S. Postal Service at no charge and will arrive in a plain, weather and tamper-proof pouch, with packaging accommodations made for temperature control if needed. Overnight delivery is available, at an additional cost. The cost varies depending on the destination city and state.

Home Delivery Mail Order Program Copayments You will be responsible to pay the applicable copayment to Express Scripts for each prescription or authorized refill dispensed by Express Scripts under the mail order program. In those instances where your copayment would otherwise be greater than the pricing for any drug covered, you will pay the lower price. Express Scripts may suspend the mail order services to you if you are in default of any copayment amount due.

Mail order pharmacies will dispense covered prescription drugs to you, and dispense generic drugs when authorized, in accordance with applicable laws and regulations in the state in which the mail order pharmacy is located. All matters pertaining to the dispensing of covered drugs or the practice of the pharmacy in general, are subject to the professional judgment of the dispensing pharmacist. Any drug that cannot be dispensed in accordance with the manufacturer, or regulatory protocols, may be excluded from coverage by Express Scripts.

Mail Order Opt-Out Program Your plan includes the Mail Order Opt-Out program (Opt-Out) called the Express Scripts Select Active Choice Program. The Opt-Out program is designed to provide more flexibility in situations where mail order requirements create an undue hardship. The program provides you with the choice to fill maintenance or long-term prescriptions through Express Scripts Pharmacy Home Delivery Service or at a retail pharmacy location. If you elect to opt-out of the mail order program:

You will not be subject to the plan’s requirement to fill maintenance or long-term prescriptions through mail order after three fills (one initial fill plus two refills) at the retail pharmacy.

You may only receive up to a 31-day supply at a retail pharmacy.

You will pay the plan’s retail copayment.

You can still choose to fill your prescriptions through mail order, even if you elect to opt-out.

Obtain new prescriptions for medications you wish to fill at a retail pharmacy. When you opt-out of the mail order program, your election applies to all current medications and future prescriptions.

The opt-out feature does not apply to specialty medications. Specialty prescriptions are provided through Accredo Health Group, Inc., an Express Scripts specialty pharmacy (please see Express Scripts Specialty Pharmacy Program explanation below). To opt-out of the plan’s requirement to fill maintenance or long-term prescriptions through mail order after three fills at the retail pharmacy, call Express Scripts toll-free at 1 (877) 603-1032 and provide your identification number located on your prescription drug card. Spouses and dependent children age 18 and older must call separately to opt-out.

Worry-Free Fills You can request automatic refills of your mail order medications through the Worry-Free Fills Program online at www.Express-Scripts.com at the time you fill your prescription or by calling Express Scripts at 1 (866) 544-1798. The Worry-Free Fills program is a service that offers you the convenience of automatically sending your next month’s refill once your estimated remaining days’ supply reaches ten (10) days. You will receive a call seven (7) days prior to shipment to notify you that your medication is being shipped.

A prescription is eligible for the Worry-Free Fills program if:



1) It is dispensed by the home delivery Express Scripts Pharmacy, 2) You have taken the medication for a minimum of 30 days, 3) The prescription will not expire before your next refill, and 4) It is for at least a 56 day supply.

Certain drugs, such as controlled substances, over-the-counter medications, and specialty drugs, are not eligible for the Worry-Free Fills program.

Starting Worry-Free Fills

If you wish refill a prescription automatically through the Worry-Free Fills program, you may do so at the time you place your order online if your medication meets the eligibility criteria. When ordering, make sure there is a check mark in the box that says: ‘Automatically refill this prescription from now on with Worry-Free Fills’ on the ‘Review Your Order’ page. Express Scripts will automatically send you your next refill. You can also enroll your eligible prescriptions by calling the toll-free Member Services phone number 1 (866) 544-1798.

Please note that certain medications are not eligible for Worry-Free Fills. The Worry-Free Fills option is not displayed if the medication is not eligible. To find out if any of the prescriptions you are currently taking are eligible for Worry-Free Fills, go to www.Express-Scripts.com, under the ‘Manage Prescriptions’ menu, choose ‘Manage Automatic Refills’ to access the Worry-Free Fills program management page.

From the Worry-Free Fills program management page online, you may choose to enroll all current and future medications eligible for the Worry-Free Fills program or just specific medications. This is the same location where you can turn off Worry-Free Fills. You may also enroll or cancel Worry-Free Fills by calling the toll-free Member Services phone number 1 (866) 544-1798.

Canceling Worry-Free Fills You may remove a prescription from the Worry-Free Fills program at any time without cancelling the current order through the Worry-Free Fills program management page (described above) and clicking on the "Turn off Worry-Free Fills for this Prescription" link next to the medication you want to remove from Worry-Free Fills or call the toll-free Member Services phone number 1 (866) 544-1798. Removing a prescription from the Worry-Free Fills program will not cancel the pending order. However, you will need to order any subsequent refills online, call 1 (866) 544-1798, or mail in a refill slip with an order form.

See the Appendix for Frequently Asked Questions (FAQs) for Worry-Free Fills if you require more information.

IMPORTANT NOTE: If you are no longer taking a prescription or your dosage has changed, it is important that you contact Express Scripts immediately to turn off automatic refills to avoid any unnecessary fills and wasted medication. Even though you may only be paying a small copayment for your prescription, the actual cost for the medication is likely to be hundreds, if not thousands of dollars charged to the State.

Notify Express Scripts immediately to help avoid wasteful spending and unwanted medications by turning off Worry-Free Fills when no longer needed.



Retail Pharmacy Program You can use a participating retail pharmacy for short-term prescriptions (such as antibiotics to treat infections) or other non-maintenance medications (such as sleep agents and pain relief). You may obtain up to a 31-day supply of covered medication for each prescription or refill. Be sure to show your Express Scripts member ID card at the pharmacy and pay your retail copayment for each prescription. You may fill maintenance or long-term prescriptions at the retail pharmacy for up to three fills (one initial fill plus two refills). For additional fills, the plan requires you to fill maintenance or long-term prescriptions through the mail order program. If you choose to fill your maintenance or long-term prescriptions at the retail pharmacy after the three fills allowed by the plan, you will be responsible for 100% of the medication’s cost unless you elect to opt-out of mail order (please see Mail Order Opt-Out Program section for more information). If the total cost for your prescription is less than the applicable copayment, you will pay the lesser cost. At the point of sale, your payment will not be greater than the Usual and Customary (U & C) price of the participating pharmacy. The U & C price means the usual and customary retail price charged by a participating pharmacy to individual retail customers in the ordinary course of business for a prescription or refill. In those instances where your copayment would otherwise be greater than the U & C Price of the participating pharmacy, you will pay only the U & C cost. Participating pharmacy means a retail pharmacy that has entered into an arrangement with Express Scripts to participate in Express Scripts’ Network. The network of participating pharmacies that comprises Express Scripts’ network may be modified from time to time. To find a participating Express Scripts pharmacy go to www.Express-Scripts.com under the ‘Manage Prescriptions’ menu, choose the ‘Locate a Pharmacy’ link or call Express Scripts Member Services at 1 (866) 544-1798. A non-participating pharmacy is a licensed retail pharmacy that is not a participating pharmacy. If you use a non-participating retail pharmacy, you must pay the entire cost of the prescription and then submit a reimbursement claim to Express Scripts by completing the Express Scripts Coordination of Benefits/Direct Claim Form. This form is found at http://www.Express-Scripts.com under the ‘Health & Benefits Information’ menu. Select ‘Print & Request Forms & Cards’ from the drop down menu. The form can be requested by calling Express Scripts Customer Service at 1 (866) 544-1798. Claims must be submitted within 365 days of the prescription purchase date. When you use a non-participating pharmacy, you will be reimbursed the amount the drug would have cost at a participating retail pharmacy, minus your retail copayment. To find a participating retail pharmacy near you:

Log-on to www.Express-Scripts.com, under the ‘Manage Prescriptions’ menu, choose the ‘Locate a Pharmacy’ link.

Ask at your retail pharmacy whether it participates in the Express Scripts network.

Express Scripts Specialty Pharmacy Program Accredo specialty pharmacy is a mail order facility dedicated to dispensing specialty medications. Some conditions, such as multiple sclerosis, Hepatitis C, rheumatoid arthritis, cystic fibrosis, infertility, pulmonary hypertension, RSV prophylaxis, Gaucher disease, and growth hormone deficiency, are treated with specialty drugs. Specialty drugs means those pharmaceutical products that are generally biotechnical in nature, with many requiring injection, or other non-oral methods of administration, and that have special shipping or handling requirements.





Members who are eligible for services through Accredo will receive support from pharmacists and nurses who are trained in specialty medications, their side effects, and the conditions they treat. Also, because many of these medications require injection or special handling, members will receive:

Expedited shipping of specialty medications to their home or doctor's office, where allowable by law.

Supplemental supplies, such as needles and syringes, that are needed to administer the medication.

Scheduling of refills and coordination of services with home care providers, case managers, and doctors or other healthcare professionals.

All specialty medications will be provided by Accredo Health Group, Inc., through Express Scripts Specialty Pharmacy Program and require Prior Authorization. If you are prescribed a specialty medication you should contact Express Scripts Specialty Pharmacy at 1 (800) 803-2523. Emergency or urgent supplies may be filled at the retail pharmacy only by contacting Express Scripts Specialty Pharmacy at 1 (800) 803-2523. Your copayments are determined by the day supply dispensed for specialty prescriptions. If your prescription is filled monthly or more frequently (a 31-day supply or less), the retail pharmacy copayment will apply. If your prescription can be filled for more than a 31-day supply, the mail order copayment will apply. For additional information, call the Express Scripts at 1 (800) 803-2523. If your provider needs to contact Accredo directly, they can call Accredo at 1 (800) 987-4904 (option 5) or they can fax a specialty prescription to 1 (800) 391-9707.

Other Important Pharmacy Program Information

The Generic Drug Advantage Generic drugs may have unfamiliar names, but they are safe and effective substitutes to brand name medications without the brand name cost. There are two types of generic medications: generic equivalents and generic alternatives.

A generic equivalent is a medication that contains the same active ingredient and strength as the brand name drug.

A generic alternative is a medication that contains a different active ingredient then the brand name drug but is clinically proven to treat the same condition.

Both types of generic medications are manufactured according to the same federal regulations. Prescriptions filled with generic drugs often have a lower copayment. Therefore, you may be able to obtain the same health benefits at a lower cost. You should ask your doctor, or pharmacist, whether a generic equivalent or alternative drug would be right for you. You may be able to receive the same treatment results and reduce your expenses.

See the Appendix for Frequently Asked Questions (FAQs) on Generic Medications if you require more information.

Medications Preferred By Your Plan Design The State of New Hampshire’s prescription drug benefit program includes a list of prescription drugs, called the National Preferred Formulary, that are preferred by Express Scripts because of their safety,


clinical effectiveness and ability to help control prescription drug costs. This drug list has a wide selection of generic and brand-name medications that have been evaluated for inclusion by a panel of physicians and pharmacists. The drug list may be modified by Express Scripts from time to time as a result of factors including, but not limited to, medical appropriateness, manufacturer rebate arrangements, and patent expirations. On an annual basis, Express Scripts makes modifications to their National Preferred Formulary. These changes are based on recommendations from the panel of physicians and pharmacists who continually review and compare the medications, including new drugs and generics. As a result, some safe and effective drugs become “preferred” and others may become “non-preferred.” If a change to the formulary results in an increased copayment or a change in coverage, Express Scripts will communicate the changes with you as well as participating pharmacies and/or physicians. At that time, you will be provided with a more cost effective preferred option to your medication. You should talk to your provider to determine which medication is right for you. If your provider determines that you must continue taking the non-preferred brand, you will be responsible for the higher copayment amount. Express Scripts also determines if medications are excluded from the formulary drug list. A list of these medications can be found on www.Express-Scripts.com, under the Benefit & Account Notifications box at the bottom of the home page. In most cases, if you fill one of these prescriptions, you will be responsible to pay the full retail cost of the drug. The list of excluded medications is subject to the same annual review and notification process as mentioned above. If your provider believes that your treatment requires one of the excluded medications, a prior authorization is required. To initiate the prior authorization process, ask your provider to contact Express Scripts at 1 (800)753-2851. For additional information about Express Scripts’ formulary, go to www.Express-Scripts.com, under the ‘Manage Prescriptions’ menu, select the ‘Price a Medication’ link or call Express Scripts toll-free at 1 (866) 544-1798.

Generic Step Therapy For certain brand-name medications, your plan requires you to try a generic equivalent medication, or front-line drug, first before your fill the more expensive brand name drug. Brand-name medications, or back-up drugs, will be covered under your plan if your prescription history shows within a specific time period that you have tried a generic equivalent. This is called Generic Step Therapy. Generic Step therapy is a program for people who take prescription drugs regularly to treat a medical condition, such as arthritis, asthma or high blood pressure. It allows you and your family to receive the affordable treatment you need and helps the State minimize prescription drug costs. In step therapy, drugs are grouped in categories, based on treatment and cost:

Front-line drugs — the first step — are generic and sometimes lower-cost brand drugs proven to be safe, effective and affordable. In most cases, you will be required to try these drugs first because they usually provide the same health benefit as a more expensive drug, at a lower cost.

Back-up drugs — Step 2 and step 3 drugs — are brand-name drugs that generally are necessary for only a small number of patients. Back-up drugs are the most expensive option.

Always talk with your doctor to determine if the generic equivalent is appropriate for you. If your doctor determines the generic is not effective for you because of a medical condition or allergy, or you have tried the recommended generic equivalent in the past with unsuccessful results, ask your doctor to contact Express Scripts at 1 (800) 753-2851 to request a Prior Authorization (PA). If the PA is approved, the brand-name medication, as prescribed by your doctor, will be covered and you will be charged the applicable brand-name copayment. If the PA is not approved, you will be required to




pay the full cost of the brand-name medication or you can consider changing to an equivalent generic upon further discussions with your doctor. Please note the additional cost you pay will not apply toward your calendar year out-of-pocket maximum. The first time you submit a prescription that has a generic equivalent available and is subject to step therapy, you will be informed by the pharmacy that you need to first try a front-line drug if you don’t want to pay full price for your prescription drug. To receive a front-line drug:

Ask your pharmacist to call your doctor and request a new prescription for a front-line drug, or

Contact your doctor to get a new prescription for a front-line drug. Only your doctor can change your current prescription to a front-line drug or request a prior authorization for the medication to be covered by your program. For additional information about Express Scripts’ formulary drugs that require step therapy, go to www.Express-Scripts.com, under the ‘Manage Prescriptions’ menu, select the ‘Price a Medication’ link or call Express Scripts toll-free at 1 (866) 544-1798.

See the Appendix for Frequently Asked Questions (FAQs) on Generic Step Therapy if you require more information.

Prior Authorization Requirements Prior authorization is a program that helps you get prescription drugs you need with safety, savings and – most importantly – your good health in mind. It helps you get the most from your healthcare dollars with prescription drugs that work well for you and that are covered by your prescription benefit. It also helps control the rising cost of prescription drugs for everyone in your plan. The program monitors certain prescription drugs and their costs so you can get the right medication at the right cost. It works much like healthcare plans that approve certain medical procedures before they’re done, to make sure you’re getting tests you need. If you’re prescribed a certain medication, it may need a prior authorization. A prior authorization makes sure you’re getting a cost-effective prescription drug that works for you. For instance, prior authorization ensures that covered medications are used for treating medical problems rather than for other purposes. Example: A medication may be in the program because it treats a serious skin condition, but it could also be used for cosmetic purposes, such as reducing wrinkles. To make sure your medication is used to treat a medical condition and promote your health and wellness, your plan may cover it only when a doctor prescribes it for a medical problem. Express Scripts consults with your medical professional. If you’re told that your prescription needs a prior authorization, it simply means that more information is needed to determine if your medication can be covered. Only your doctor (or sometimes a pharmacist) can provide this information and request a prior authorization. Your plan requires prior authorization for the following prescription medications:

Erythroid stimulants

Injectable Fertility agents (except Oral Fertility Medications)

Growth hormones

Interferon agents

Multiple sclerosis agents



Myeloid stimulants

Platelet Proliferators

Injectable Rheumatoid Arthritis Agents

Xolair

Raptiva

Tysabri

Apokyn

Wellbutrin and its generics

Botox and Myobloc for non-cosmetic purposes

If you submit a prescription for a medication that requires prior authorization, your pharmacist will tell you that approval is needed before the prescription may be filled. The pharmacist will recommend that you ask your doctor to call the toll-free number 1 (800)753-2851 to request a prior authorization approval. If you use the Mail Order Program, your doctor will be contacted directly. When a prior authorization is triggered, more information is needed to determine whether your use of the medication meets your plan’s coverage conditions. You and your doctor will be notified of the decision in writing. If coverage is approved, the letter will indicate the amount of time for which coverage is valid, typically not more than one year or twelve (12) months. If coverage is denied, an explanation will be provided, along with instructions on how to submit an appeal. Only your doctor can request or renew a prior authorization for the medication to be covered by your program. For additional information about Express Scripts’ formulary drugs that require prior authorization, go to www.Express-Scripts.com, under the ‘Manage Prescriptions’ menu, select the ‘Price a Medication’ link or call Express Scripts toll-free at 1 (866) 544-1798.

See the Appendix for Frequently Asked Questions (FAQs) on Prior Authorizations if you require more information.

Quantity Limits Your plan includes quantity limits for certain medications limiting the amount of medication for which your plan will pay. Quantity limits help to ensure you receive your medications in amounts approved by the U.S. Food and Drug Administration to safely and effectively treat your condition(s). It helps to address patient safety concerns and prevent potential for abuse and misuse. To verify if the medication being prescribed by your doctor has a quantity limit visit Express Scripts at www.Express-Scripts.com or call Express Scripts toll-free at 1 (866) 544-1798. The limits do not prevent you from obtaining additional quantities as prescribed by your doctor. Your plan will pay for additional quantities if your doctor documents that they are clinically appropriate for treatment. If your prescription exceeds the quantity limits allowed by the plan, talk with your doctor to determine what quantities are effective for treatment. Ask your doctor to call Express Scripts at 1 (800)753-2851 to request a Prior Authorization (PA) if he/she determines additional medication is appropriate. If the PA is approved, the additional quantity as prescribed by your doctor may be obtained and you will pay the applicable copayment for the additional medication. If the PA is not approved, you will pay 100 percent of the cost for the additional quantities if you choose to obtain the additional supply at a retail pharmacy location. Please note the additional cost you pay will not apply toward your calendar year out-of-pocket maximum. For additional information about Express Scripts’ formulary drugs that require quantity limits, go to www.Express-Scripts.com, under the ‘Manage Prescriptions’ menu, select the ‘Price a Medication’ link or call Express Scripts toll-free at 1 (866) 544-1798.





Coverage of Preventive Medications Under the Affordable Care Act (ACA), commonly known as health care reform, certain preventive medications, including over-the-counter (OTC) medications, are covered without charging a copayment, coinsurance or deductible. Your plan, in consultation with Express Scripts, has developed a list of medications and criteria (i.e., gender and age) to support preventive medication requirements based on the recommendations of the U.S. Preventive Services Task Force (USPSTF) and the Centers for Disease Control and Prevention (CDC) to be covered under the pharmacy benefit. Your plan will provide medications in the drug categories listed below at no-cost share ($0 copayment) specific to age and gender requirements of the ACA*. All medications require a prescription, including over-the-counter medication. Drug or Drug Category Criteria

Aspirin (to prevent cardiovascular events)

Men ages 45 to 79 years and women ages 55 to 79 years Generic OTC < or = to 325mg

Aspirin for Preeclampsia Women < 55 years Generic only, low dose 81 mg, after 12 weeks gestation in women at high risk for preeclampsia

Fluoride Children older than 6 months of age through 5 years old Generic only (OTC and prescription products)

Folic Acid Women through age 50 years Generic only (OTC and prescription products) 0.4 – 0.8 mg

Iron Supplements Children ages 6 months to 12 months who are at risk for iron deficiency anemia Generic only (OTC and prescriptions products)

Smoking Cessation

Age limit 18 or older. Prior Authorization required for Wellbutrin and its generics, as these medications are not approved by the FDA for tobacco treatment. Generic prescriptions, generic OTC medications including patches and gum and Chantix.

Vitamin D Men and Women ages 65 or older Generic OTC and prescription products

Women’s Preventive Services & Contraception Coverage

Women through age 50 1) Barrier contraception – i.e. cervical caps, diaphragms 2) Hormonal contraception (generic and select brands) - oral, transdermal,

intravaginal, injectable 3) Emergency contraception 4) Implantable medications 5) Intrauterine contraception 6) OTC barrier contraceptive methods (with a prescription)

Breast Cancer Primary Prevention (Tamoxifen or Raloxifene)

High-risk women age 35 or older who do not have breast cancer or have never been diagnosed with breast cancer, ductal carcinoma in situ (DCIS), or lobular carcinoma in situ (LCIS) and with an estimated 5-year risk of 3% or greater (based on breast cancer risk model estimates). Physician must request review process to determine eligibility for $0 cost share.

Bowel Preparation for Colonoscopy Screening

Men and women ages 50 through 75 years. Generic and brand prescription and OTC preparations. Two prescriptions per 365 days.

Immunizations/Vaccinations Recommended ages per Advisory Committee on Immunization Practices


*The government guidelines are updated periodically to reflect new scientific and medical advances, so this list may be subject to change.

For additional information about Express Scripts’ formulary drugs that have a $0 copay, go to www.Express-Scripts.com, under the ‘Manage Prescriptions’ menu, select the ‘Price a Medication’ link or call Express Scripts toll-free at 1 (866) 544-1798.

Appeal Administration When a member or physician requests an appeal and additional information is provided, it is reviewed and evaluated by the Express Scripts Appeals Unit to determine if the drug use meets coverage conditions specified or intended by the State of New Hampshire Prescription Drug Program according to the procedures set forth below. Appeal decisions are made by a pharmacist, prescription benefit specialist or panel of clinicians. The Express Scripts appeal unit may also decide to forward a first level or second level appeal to a third party utilization management company (Independent Review Organization) for review and decision. Appeal procedures apply to appeals of adverse benefit determinations based on medical necessity, appropriateness or effectiveness of a covered benefit. The external review coordination procedures apply to appeals of adverse benefit determinations based on medical necessity, appropriateness or claims involving medical decision making after all internal levels of appeal process have been exhausted. Appeals Related to Eligibility Appeals related to eligibility to participate in the plan and related to plan design are coordinated by State of New Hampshire Division of Personnel at:

State of New Hampshire Division of Personnel

28 School Street Concord, NH 03301-6313

Phone: (603) 271-3262 FAX: (603) 271-1422

TDD Access: Relay NH 1-800-735-2964

Rescission of Coverage Rescission of Coverage is subject to the same rescission of coverage provisions in the medical plan benefit booklet. Express Scripts completes appeals per business policies that are aligned with state and federal regulations. Appeal decisions are made by an Express Scripts Pharmacist, Physician, and panel of clinicians or independent third party utilization management company. Submitting a Request for Appeal Other than appeals related to eligibility to participate in the plan, written requests for appeal should be mailed to:

Express Scripts 6625 W 78

th St

Bloomington, MN 55439

Attn: Appeals Team If you have questions about the appeals process, call the toll-free Member Services phone number on the back of your Express Scripts member ID card or 1 (866) 544-1798.



Level 1 Appeals To initiate a level 1 appeal, a Plan Participant (all references to Participant in the Appeals section of this Benefit Booklet include the Retirees and/or covered Dependents) must submit a written request for an appeal to Express Scripts within one hundred eighty (180) days of receipt of a notice of denial of medication(s) under the Plan. The Participant must tell, or present evidence, e.g. documents, and testimony to, Express Scripts the reason why the denial should be overturned and include any information supporting the appeal. Express Scripts will evaluate or forward the appeal request and all accompanying information to the appropriate review entity. For standard cases, the Participant will receive in writing within one (1) working day an acknowledgement of receipt of the appeal request which includes allowance of five (5) business days for the Participant to submit any additional information. The acknowledgement letter will also contain the contact information for the person who is handling the appeal. Level 2 Appeals To initiate a level 2 appeal, a Plan Participant must submit a written request for an appeal to Express Scripts within ninety (90) days of receipt of an adverse determination of a Level 1 appeal under the Plan. The Participant must tell, or present evidence, e.g. documents, and testimony to, Express Scripts demonstrating the reason why the denial should be overturned and include any information supporting the appeal. Express Scripts will evaluate or forward the appeal request and all accompanying information to the appropriate review entity. Express Scripts completes appeals per business policies that are aligned with state and federal regulations. Appeal decisions are made by an Express Scripts Pharmacist, Physician, a panel of clinicians, or independent third party utilization management company. For standard cases, the Participant will receive in writing within one (1) working day an acknowledgement of receipt of the appeal request which includes allowance of five (5) business days for the Participant to submit any additional information. The acknowledgement letter will also contain the contact information for the person who is handling the appeal. Time frames for Processing Appeals of Pharmaceutical Adverse Determinations Standard Appeals: Standard, non-expedited Level 1 appeals involving the review of a denial of coverage for medication requests will be completed within 15 calendar days for pre-service appeals and 30 calendar days for post-service appeals. The appeal review period may be extended for a maximum of ten (10) calendar days if:

1) there is reasonable cause beyond the reviewer’s control for the delay; 2) can show that the delay will not result in increased medical risk to the Participant; and 3) provide a written progress report to the Participant and the related provider within the forty

(40) day review period. Participants must agree, in writing, to a request to extend a deadline. Expedited Appeals: Some appeals of denials relating to claims involving urgent pharmaceutical care are processed on an expedited basis. Expedited decisions are made when:

a Participant’s life or health or ability to regain maximum function would be jeopardized by following the standard appeal process and time frames; or

in the opinion of an attending provider with knowledge of the Participant’s medical condition, delay would subject the Participant to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

Provider Requests In cases that require an expedited decision of a medication request, based at the request of an attending provider, a decision will be made within seventy-two (72) hours of the receipt of the request or more rapidly depending on medical exigencies.


Participant Requests If a Participant requests an expedited decision, the request will be reviewed. If it is determined that the request for an expedited appeal is medically necessary, a decision will be made within seventy-two (72) hours of the request or more rapidly depending on medical exigencies. All required information will be transmitted between the reviewer, the applicable provider, and the Participant by the quickest means possible. If it is determined that a request for an expedited appeal is not medically necessary, the Participant will be notified and the appeal processed within fifteen (15) calendar days. Internal Review of Appeal of Adverse Determination Clinical appeals (claims involving medical judgment) will be reviewed by an Express Scripts Pharmacist, Physician, panel of clinicians or independent third party utilization management company. The reviewer will represent the same or similar specialty of the prescribing physician and/or with training and experience in the relevant field, not involved in the initial determination, nor by a subordinate of the person resolving the claim initially or who has any conflict of interest. Administrative appeals (no medical decision making) will be reviewed by an Express Scripts pharmacist consultant not involved in the initial determination, nor by a subordinate of the person resolving the claim initially or who has any conflict of interest. The consultant will re-review the request to make a determination regarding whether the requested health care services are medically necessary and/or covered under the Plan. Notice of Decision on Appeal of Adverse Determination If the reviewer consultant decides to reverse an initial adverse determination, the reviewer will approve coverage of the medication. The applicable Participant and the applicable provider will be notified by mail or electronic means (fax) within seventy-two (72) hours of such decision. If the reviewer consultant decides to uphold an initial adverse determination, the applicable Participant and the applicable provider will be notified that the adverse determination has been upheld by written or electronic means within seventy-two (72) hours of such decision. Written notification must be provided in a linguistically appropriate manner. The Participant will be given appeal rights to pursue an External Review. Where there is an ongoing course of treatment that is the subject of the denied claim and an internal appeal, the plan will not reduce or terminate coverage of the treatment pending the outcome of the appeal. External review If the Participant is dissatisfied with any internal appeals decision for clinical claims (claims involving medical decision making), the Participant may request an external review by an Independent Review Organization (IRO) as defined by Applicable Law. An IRO is an independent review organization, external to the State of New Hampshire and Express Scripts, that utilizes independent physicians with appropriate expertise to perform external reviews of appeals. The IRO will, with respect to claims involving investigational or experimental treatments, ensure adequate clinical and scientific experience and protocols are taken into account as part of the External Review process. In rendering a decision, the IRO will consider any appropriate additional information submitted by the Participant and will follow the plan documents governing the Participant’s benefits. For claims involving urgent care, a Participant may request an expedited external review if the adverse benefit determination involves:

a medical condition of the Participant for which the regular time frame would seriously jeopardize the life or health of the Participant or would jeopardize the Participant’s ability to regain maximum function, and

the Participant filed a request for an expedited internal appeal; Or, if the final internal adverse benefit determination involved:

a situation where the Participant had a medical condition where that time frame would pose such jeopardy, and


if the final internal adverse benefit determination concerned an admission, availability of care, continued stay or health care service for which the Participant received emergency services and was not discharged from a facility.

Individuals in urgent care situations and individuals receiving an ongoing course of treatment may proceed with an expedited external review by an IRO at the same time as the internal review process occurs. There are no fees or costs imposed on a Participant for the external review of an appeal. The Participant’s decision as to whether or not to submit a denied appeal for external review will have no effect on the Participant’s rights to any other benefits under the Plan. When an appeal is denied by Express Scripts or a reviewer consultant, the Participant will receive a letter that describes the process to follow if the Participant wishes to pursue an external review of an appeal through an IRO. If a Participant files a request for an external review of an appeal with an IRO:

The external review may only be requested after exhaustion of the required Internal Appeal procedures under the Plan, unless an expedited external review of a claim involving urgent care or an ongoing course of treatment is requested. Accordingly, the Participant must first submit an appeal with Express Scripts and receive a denial of appeal before requesting an external review of an appeal with an IRO.

After a Participant receives a denial of an appeal, the Participant must submit the request for external review of appeal with an IRO in writing within 4 months from the date of receipt of the adverse benefit determination, extended to the next working day if the date falls on a weekend or federal holiday.

The IRO will forward a copy of the final appeal denial letter and all other pertinent information that was reviewed in the appeal to the IRO. The Participant may also submit additional information to be considered. For standard non-expedited appeals, the Participant will have ten (10) business days to submit additional information to the IRO.

Within five days after receipt of the request for external review, the Plan will complete a preliminary review to determine if the Participant was covered under the Plan at the time the service was requested or provided; whether the adverse benefit determination relates to the Participant’s failure to meet the eligibility requirements of the Plan; whether the Participant has exhausted the Plan’s internal appeal process; and whether the Participant has provided all of the information and forms required to process an external review. Within one business day after completion of this preliminary review, the Plan will provide the Participant written notification giving any reasons for the ineligibility of the request for external review and describing the information or materials required, and the Plan will allow the Participant to perfect a request for external review within the four month filing period or within the 48 hour period following receipt of the notification, whichever is later.

The Participant will be notified of the decision of the IRO within 45 days of the receipt of the request for the external review of an appeal for standard, non-urgent claims. The IRO’s decision will include:

a) A general description of the reason for the request for external review;

b) The dates the IRO received the assignment to conduct the external review and the date of their decision;

c) Reference to the evidence or documentation, including specific coverage provisions and evidence-based standards, considered in reaching their decision, taking into account


adequate clinical and scientific experience and protocols with respect to claims involving experimental of investigative treatments;

d) A discussion of the principal reason or reasons for its decision, including the rationale for its decision;

e) A statement that judicial review may be available; and

f) Current contact information, including the phone number for any ombudsman established under the PHS Act.

g) In the event of an expedited external appeal for claims involving urgent care, the IRO will make the decision as expeditiously as the Participant’s medical condition or circumstances require, but in no event more than 72 hours after the IRO receives the request for an expedited external review and, if the notice is not in writing, within 48 hours after the date of providing the verbal notice, the IRO will provide written confirmation of the decision to the Participant and the Plan. Written notice must be provided in a linguistically appropriate manner. The notice will provide the opportunity to request diagnosis and treatment codes and their meanings.

h) The decision of the IRO will be binding on the Participant as well as the Plan, except to the extent there may be other remedies available under state law.

The statute of limitations or other defense based on timeliness is suspended during the time that an external review of your appeal is pending.

Experimental or Investigational Services/Treatment Exclusions Experimental or investigational services/treatments are not covered benefits. Experimental/investigational means any treatment, procedure, facility, equipment, drug, device or supply not accepted as standard medical practice in the state services are provided. In addition, if a federal or other governmental agency approval is required for use of any items and such approval was not granted at the time services were administered, the service is experimental. To be considered standard medical practice and not experimental or investigational, treatment must meet all five of the following criteria:

1. A technology must have final approval from the appropriate regulatory government bodies; 2. The scientific evidence as published in peer-reviewed literature must permit conclusions

concerning the effect of the technology on health outcomes; 3. The technology must improve the net health outcome; 4. The technology must be as beneficial as any established alternatives; and 5. The improvement must be attainable outside the Investigational settings.

Coordination of Benefits Coordination of Benefits is the process in which two or more health insurers cover the same person(s) but limit the total benefit payable for a claim to an amount not exceeding the total cost of the claim. If any covered dependents have primary prescription drug coverage through another employer-sponsored plan, Medicaid or Medicare, you have the ability to submit deductibles, copayments, or co-insurance not covered by the primary plan for reimbursement under this plan. Reimbursement will be provided for covered drugs as outlined in the “What is Covered” section of this Benefits Booklet and subject to any plan design limitations. Reimbursement should be requested by completing the Express Scripts Prescription Drug Reimbursement/Coordination of Benefits Claim Form found on www.Express-Scripts.com under the Health & Benefits Information menu. Select ‘Print & Request Forms & Cards’ from the drop down menu. The form can be found and printed under the ‘Claim forms for retail pharmacy purchases’ section. You may also have a form mailed to you by calling Member Services at 1 (866) 544-1798.



You must first submit the claim to the primary insurance carrier. Once the statement from the primary plan is received from the primary carrier, complete the Prescription Drug Reimbursement/Coordination of Benefits Claim Form, tape the original prescription receipts in the spaces provided at the top of this page, and attach the statement from the primary plan, which clearly indicates the cost of the prescription and what was paid by the primary plan.

Return the completed Prescription Drug Reimbursement/Coordination of Benefits Claim Form and

receipt(s) to:

Express Scripts ATTN: Commercial Claims P.O. Box 2872 Clinton, IA 52733-2872 You may also fax your claim form to: 1 (608) 741-5475 For further information on Coordination of Benefits or for an explanation on the reimbursement of a claim, please call the Member Service at 1 (866) 544-1798.

Express Scripts Contact Information Express Scripts Member Services Express Scripts Member Services is available 24-hours a day, 7-days a week by calling toll-free 1 (866) 544-1798. Express Scripts’ Telecommunications Device (TDD) TDD assistance is available for hearing-impaired members by calling 1 (800) 759-1089. You can send Member Services a secure email through www.Express-Scripts.com. See the insert below on how to access the online inquiry page.



Other helpful toll-free phone numbers mentioned throughout this Benefits Booklet:

Express Scripts’ Select Active Choice (Mail Order Opt-Out) Program: 1 (877) 603-1032

Express Scripts’ Prior Authorizations Department:1 (800) 753-2851

Express Scripts’ Prescription Form (Provider Only) Fax: 1 (800) 837-0959

Express Scripts’ Prescriber Assistance: 1 (888) 327-9791

Express Scripts’ Specialty Pharmacy, Accredo: 1 (800) 803-2523

Express Scripts’ Specialty Pharmacy, Accredo (for Providers): 1 (800) 987-4904, option 5

Express Scripts’ Specialty Pharmacy FAX, Accredo FAX: 1 (800) 391-9707

Express Scripts’ self-service payment application (automated system only): 1 (800) 948-8779

The Frequently Asked Questions link is found on the bottom of the www.Express-Scripts.com Home Page after you log-on to your personal account. From the Frequently Asked Questions page, you can access the Help Center for several different accessibility resources and methods to contact Express Scripts Member Services. Member Services can also help connect you to language translation and interpreter service.



You can also learn more about your prescription benefits through the State of New Hampshire’s website at http://www.admin.state.nh.us/hr/health_benefits_active.html.

Other Things You Should Know

Drugs and your safety The risks associated with drug-to-drug interactions and drug allergies can be very serious. Express Scripts will check for potential interactions and allergies, whether you use the Mail Order Program or the Retail Program. Express Scripts will also send this information electronically to participating retail pharmacies.

Express Scripts may contact your doctor about your prescription If you are prescribed a drug that is not on the preferred drug list but an alternative preferred drug exists, Express Scripts may contact your doctor to ask whether that drug would be appropriate for you. Please be assured that your doctor will always make the final decision on all your medications. If your doctor agrees to use a plan-preferred drug, you will generally save money.

Express Scripts protects your privacy Because your privacy is important, Express Scripts complies with federal privacy regulations. They use health and prescription information about you and your dependents only to administer the State of New Hampshire’s prescription drug plan and to fill your mail order prescriptions.

http://www.admin.state.nh.us/hr/health_benefits_active.html


APPENDIX Frequently Asked Questions (FAQs) for the following topics:

Mail Order Pharmacy

Packaging and Shipping of Mail Order Medications

Worry-Free Fills

Generic Medications

Generic Step Therapy

Prior Authorizations

Controlled Substances

FAQs about Mail Order Pharmacy Q: How should my doctor write my home delivery prescription? A: To maximize your savings, ask your doctor to write your prescription for a 90-day supply with refills when appropriate instead of 30-day supply with refills. It is important to ask for a 90-day supply, as opposed to a 30-day supply, in order to receive up to 90 days of medication for one home delivery co-payment. Please note that you will be charged a home delivery co-payment regardless of the number of days' supply written on the prescription, so make sure your doctor has written the prescription for 90 days. Please note that the actual quantity and/or days' supply may vary for each drug. Your doctor's instructions on how to take the medication, state and federal dispensing guidelines, or how the medication is packaged may impact the quantity and/or days' supply you can receive. Q: How long does it take to get my medications when I use home delivery? A: First-time orders will usually be delivered within 8 to 11 days after Express Scripts receives your order. Refills usually arrive in less time. Refills ordered online are usually delivered within 3 to 5 days after Express Scripts receives your order. For refills mailed in, please allow 6-9 days. Renewals ordered online will usually be delivered in 5-8 days once Express Scripts receives your physician's approval of the renewal prescription. Mailed-in renewals will usually arrive in 7-11 days, once your order is received. New and renewal prescriptions faxed from your doctor will usually be delivered in 5-8 days. Please allow 24-48 hours for the prescription to appear online once your doctor has faxed in the prescription. The best time to reorder is when you have about a 14-day supply of your medication remaining. This will help ensure that you receive the medication you need, when you need it. Estimates for shipping may change if the order is processed differently than expected or if the delivery method is changed while the prescription is in process. The most up-to-date status is provided online as soon as it is available. Note: Certain medications, including many drugs prescribed for narcolepsy, attention deficit disorder, and pain management, are mailed via expedited delivery, and require a signature upon delivery. Q: How are medications shipped? A: Most medications are shipped via the U.S. Postal Service at no cost to you. Medications containing


certain controlled substances are shipped United Parcel Service (UPS). If necessary, you can request express shipping. Express shipping is also available for an additional fee. Q: What if I need to speak with a pharmacist? A: Express Scripts’ registered pharmacists are available 24 hours a day, seven days a week to answer any questions about your medications. Please call the toll-free number for Express Scripts Member Services at 1 (866) 544-1798. Q: How do I pay for my prescriptions? A: If you mailed your prescription to Express Scripts, you can enclose your payment with your order or you can be billed. If you used Express Scripts’ online services, you will be prompted for credit card information online or you can be billed. For your convenience, Express Scripts offers auto-charge, which allows you to place a credit card on file. When you enroll, Express Scripts will automatically charge any orders covered under your member number (all covered household members) to the card of your choice: American Express, Diner's Club, Discover® Network, MasterCard or Visa. To enroll, just call 1 (800) 948-8779, or select this option online when you place an order for a refill or renewal of a current prescription. Your credit card information is secured using the latest advances in commercially available security products. Q: When my doctor faxes you a prescription, what happens to it? A: When Express Scripts receives a faxed prescription from a doctor, they first make sure that the prescription is coming from a secure fax machine associated with a prescriber listed in their database. A secure fax machine is restricted from public access and is generally within a controlled area in the doctor's office. Express Scripts’ system automatically checks the incoming fax number against their database of recognized prescribers. If Express Scripts cannot determine the security of the fax line or if the incoming fax number cannot be matched against a prescriber in their database, then they contact the doctor's office to verify your prescription. Upon verification, the prescription information is entered into their system and processed. If they are unable to verify your prescription, they will attempt to contact you. If two attempts to contact you are unsuccessful, Express Scripts will send you a notification to inform you that they were unable to fill your prescription. Q: If I am going to be out of town for an extended time, how do I get an extra supply of drugs to cover me through that period? A: If you are going to be out of town for an extended period and need medication, call the toll-free number for Express Scripts Member Services at 1 (866) 544-1798 to request a vacation override once per calendar year. You must provide Express Scripts with the date you are leaving and when you plan to return. You may request up to a two (2) 31-day prescriptions in a retail pharmacy for double the applicable copayment amount. You may request up to a two (2) 90-day prescriptions via the Mail Order pharmacy for double the applicable copayment amount. In some cases, your provider may have to authorize the additional fill.

FAQs about Mail Order Packaging and Shipping Q: How can I identify a package that arrives from one of your pharmacies?


A: No matter how many packages or parcels you may receive, you can always feel confident knowing which are from the Express Scripts’ home delivery pharmacy. Just look in the upper left-hand corner of the shipping label to find the name MHS Services. Q: How will my medications be packaged? A: In most cases, Express Scripts uses heat- or glue-sealed plastic pouches, or "poly bags," to protect the prescription orders that they send from their pharmacies. This protective packaging enables them to fulfill their goal of delivering medications safely to members, and it has met the laboratory test standards set by the International Safe Transit Association. It works well with the automated packaging process used by the Express Scripts Pharmacy

SM.

When shipping your medications, Express Scripts may also use a gray plastic pouch, a brown or white corrugated box, a padded manila envelope, or an expedited carrier (for example, UPS). All of the packaging Express Scripts uses are "tamper evident," which will help members determine whether their order has been damaged or tampered with during delivery. Express Scripts’ "MHS Services" label appears on the side of each package. The label does not display the name "Express Scripts" or indicate that the package contains medications. This is done to protect your confidentiality and to reduce the possibility of theft. For prescription orders that are breakable, Express Scripts packages them by hand with bubble wrap and places them into corrugated boxes for maximum protection during delivery. Orders that are temperature sensitive require special packaging. Q: Why are my orders sometimes shipped in two or more packages? Is there a way to keep my orders in one package? A: When your medication order arrives in two or more packages, it is usually because Express Scripts has shipped it from different Express Scripts pharmacies. They split your medication order and fill it through different Express Scripts pharmacies for several reasons. For instance, a certain pharmacy may be able to provide one or more of your medications more quickly. Or your medications might be stocked at different Express Scripts pharmacies because of special requirements for those medications. (This is often the case with temperature-sensitive medications.) Also, not all Express Scripts pharmacies dispense controlled substances. Q: How will I know if my order has been shipped in more than one package? A: If your order has been shipped in more than one package, the invoice statement in each package will explain the situation. You will see a separate invoice number for each package within your order. Go to www.Express-Scripts.com to find out if your order has been divided into two or more shipments by clicking on "Prescription order status". Be assured that all of Express Scripts’ pharmacies maintain the same standard of excellence and are dedicated to dispensing your medications safely and quickly. Q: How do I change my shipping address? A: When ordering prescription medications, you may choose to receive your order at any address that Express Scripts has on file for you. Simply select the appropriate shipping address displayed from any of the addresses you have listed on your account during checkout. You can also request address changes by calling your toll-free member services number where a customer service representative would be happy to assist you with this change. NOTE: Please know that you are only changing the address where you will receive medications. You need to contact your benefits or payroll representative at the State of New Hampshire to change your address for your personnel, benefits and payroll records.



Q: I am getting a message that says you do not have an address on file for me. Why might this be? Is there a way I can change this? A: Mailing addresses initially received by Express Scripts are validated with a member's initial order. In some cases, the reason Express Scripts may not have a mailing address on file is because they may not have received complete mailing information when your benefit coverage began. Other times, you may not have placed an initial order with Express Scripts, which allows them to validate that address. Once an initial home delivery prescription order is placed, the address should remain on file until changed by the member. If Express Scripts does not have a record of an address on file, please contact Express Scripts Member Services at 1 (866) 544-1798 to rectify this situation. Q: What is your process for shipping temperature - sensitive medications? A: All drugs Express Scripts dispenses through the mail are reviewed for any unique shipping requirements, based on information from the manufacturer. In some instances, normal shipping procedures can be followed. For other items, Express Scripts will follow special shipping requirements if appropriate. When prescriptions for temperature-sensitive medications are processed, the medication will automatically be mailed to the patient via (overnight) shipping. Refills requested on Friday, Saturday or Sunday will be shipped on Monday. Most temperature-sensitive medications are shipped overnight or by 2nd-day air depending on the medication's sensitivity. These medications are shipped via a commercial shipping carrier to a street address that you provide. Please note that commercial carriers cannot deliver to a post office box. No signature is required, so you don't have to be home for delivery. Depending on the medication, a scheduling call may be made, in which case you should arrange to be home to receive the medication or to have it shipped to a relative, friend, or neighbor who will be home. If no scheduling call is needed, please be sure that these medications are retrieved and brought inside on the delivery day. Temperature-sensitive medications may also arrive in a separate package if ordered with other medications. Remember, if you ever have any questions regarding your prescription, an Express Scripts pharmacist is available to speak with you.

FAQs about Express Scripts Worry-Free Fills® Q: What is Worry-Free Fills? A: Worry-Free Fills gives you the peace of mind of knowing that your medication will be refilled and mailed to you automatically when your prescription is within 10 days of running out. There's no more worrying about ordering medications on time. Express Scripts will even send you an email approximately 2 weeks prior to the refill date to let you know that your refill is about to be processed. Q: How can I enroll a prescription in the Worry-Free Fills program? A: For each eligible prescription that you want to have automatically refilled, make sure there is a check mark in the box that says: "Automatically refill this prescription from now on with Worry-Free Fills" on the "Review your order" page. Express Scripts will automatically send you your next refill. You can also enroll your eligible prescriptions by calling your toll-free Member Services phone number. Please note that certain medications are not eligible for Worry-Free Fills. The Worry-Free Fills option is not displayed if the medication is not eligible.


Q: How can I remove a prescription from or turn off the Worry-Free Fills program? A: You may remove a prescription from the Worry-Free Fills program at any time without cancelling the current order by visiting the "Order Status" page or "Worry-Free Fills" page and clicking on the "Turn off Worry-Free Fills for this Prescription" link next to the medication you want to remove from Worry-Free Fills or call your toll-free Member Services phone number. Removing a prescription from the Worry-Free Fills program will not cancel the pending order. However, you will need to order any subsequent refills online, call 1 (866) 544-1798, or mail in a refill slip with an order form. Q: How can I cancel a pending prescription order if it is enrolled in the Worry-Free Fills program? A: You may cancel a pending prescription that is enrolled in the Worry-Free Fills program up to 48 hours before your medication is processed by visiting the "Order Status" page or "Worry-Free Fills" page and clicking on the "Cancel Prescription" link. Or you may call your toll-free Member Services phone number. If you choose to cancel a prescription that is enrolled in the Worry-Free Fills program, you will no longer receive automatic refill shipments, even if you have refills remaining. You will need to go to the "Order Center" page online to place a future order for any remaining refills, call 1 (866) 544-1798, or mail in a refill slip with an order form. Q: Why are some of my medications already checked off for Worry-Free Fills? A: Express Scripts may have pre-selected your eligible generic medications for enrollment in this program to highlight for you the convenience of automatic refills, while taking advantage of the potential lower costs offered by generics. You can choose to enroll other eligible medications to take further advantage of the convenience of Worry-Free Fills. Or, if you prefer not to receive automatic refills, you can turn off Worry-Free Fills for these medications at any time. Q: Are all my prescriptions eligible for Worry-Free Fills? A: A prescription is eligible for the Worry-Free Fills program if: 1) it is dispensed by the home delivery Express Scripts Pharmacy

SM, 2) you have taken the medication for a minimum of 30 days, 3) the

prescription will not expire before your next refill and 4) it is for at least a 56 day supply. Certain drugs, such as controlled substances, over-the-counter medications, and specialty drugs, are not eligible for the Worry-Free Fills program. Q: What happens when my current prescription runs out and I have no more refills? A: As part of the services of the Worry-Free Fills program, the Express Scripts Pharmacy will contact your doctor when you are out of refills for your medication. Once Express Scripts receives your new prescription, you will continue to receive the prescribed number of refills automatically. With Worry-Free Fills, you will receive your medication when your refill is due. There is nothing you need to do. Express Scripts will automatically ship your eligible medications when you're within 10 days of running out. Q: How can I change my medication ship date? A: You can change your medication ship date by visiting the "Order Status" page and clicking on the "Change date" link. Note that you should only extend your ship date if you think you already have enough medication on hand. Q: When will I be billed for the automatic refills?


A: You will not be billed until after your medication has been dispensed. Q: How can I remove the Worry-Free Fills check mark off my medication? A: You can remove the Worry-Free Fills check mark off a medication by simply clicking on the box next to "Automatically refill this prescription from now on with Worry-Free Fills". Q: Why should I enroll my future prescriptions for Worry-Free Fills? A: You have the option to enroll in the Worry-Free Fills program by individual prescription or for all your current and future eligible prescriptions. If you enroll your eligible future prescriptions in Worry-Free Fills®, your refill process will be one step shorter. When you enroll your future prescriptions, every new prescription eligible for Worry-Free Fills will automatically be sent to you when it's time to refill. You won't have to remember to select the Worry-Free Fills option for your enrolled prescriptions in the future. If an enrolled prescription needs to be renewed, Express Scripts will automatically contact your prescriber to authorize the renewal. Status and pricing information for future prescriptions you enroll will still appear in the Worry-Free Fills Center. You will also continue to receive a notice prior to shipment of your orders, and you will still have the option to change the shipping date or cancel any order, either on Express-Scripts.com or by calling customer service. Q: Will enrolling all my future prescriptions in Worry-Free Fills also enroll my current prescriptions? A: No; enrolling all future prescriptions automatically includes all eligible future prescriptions in Worry-Free Fills but does not enroll your current prescriptions. Your current prescriptions will need to be enrolled in Worry-Free Fills individually in either the Order Center or Worry-Free Fills Center.

FAQs about Generic Medications Q: What is a generic version of a brand-name drug? A: A generic version (or equivalent) is a medication that is generally sold under the name of its active ingredients—the chemicals that make it work—rather than under a brand-name, and it is typically much less expensive than its brand counterpart. Generic versions that have been approved by the U.S. Food and Drug Administration, or the FDA, contain the same active ingredients—and are the same in safety, strength, performance, quality, and dosage form—as their brand counterparts. Q: Does every brand-name drug have a generic version? A: Not every brand-name drug has a generic version that is available to the public. Generic versions generally become available for sale only after the patent for the brand has expired. Once the patent expires, other manufacturers can produce and sell generic versions. Q: When does a generic version become available? A: Drug manufacturers can market a generic version after the patent for the brand-name drug has expired and the generic version has been approved by the FDA. Generally, patents expire 20 years after they are initially filed, but by the time the brand-name drug has completed testing and is approved for sale, as few as 10 years may remain on the patent. Q: Why do generic drugs cost less than brand-name drugs? A: A generic drug typically costs less to develop because its manufacturer does not have to perform all


the costly clinical studies that the manufacturer of the brand had to perform during development. In developing a generic version, the manufacturer can use the clinical data that has been gathered about the brand-name drug's safety and effectiveness. Generic manufacturers also don't spend money advertising their drugs in magazines and on TV. So, generic drugs are less expensive for you and your health plan. Q: I understand that I can avoid higher costs by using generic drugs, but am I giving up quality? A: No, not at all. The FDA reviews approved generic drugs to ensure that they match their brand counterparts in safety, quality, strength, and dosage.

FAQs about Generic Step Therapy

Q: Who decides what drugs are covered in step therapy? A: In accordance with the State’s pharmacy plan design, step therapy is developed under the guidance and direction of independent, licensed doctors, pharmacists and other medical experts. Together with Express Scripts they review the most current research on thousands of drugs tested and approved by the FDA for safety and effectiveness and recommend appropriate prescription drugs for step therapy under your plan. Q: How do I know what front-line drug my doctor should prescribe? A: Only your doctor can make that decision. You can go to Express-Scripts.com (located under Manage Prescriptions / Price a Medication) for a list of your plan’s front-line drugs. For additional information about Express Scripts’ formulary drugs that require generic step therapy, go to www.Express-Scripts.com, under the ‘Manage Prescriptions’ menu, select the ‘Price a Medication’ link or call Express Scripts toll-free at 1 (866) 544-1798. Q: What if I need a prescription filled immediately at a retail pharmacy and I do not want to go through the Step Therapy process? A: If your provider wants you to take a certain medication without trying a generic or front-line medication first, they may do so through the prior authorization or override process. Until that prior authorization is approved by Express Scripts, your pharmacist may tell you that your prescription is not covered. If this occurs and you need your medication quickly, you can:




Q: What if I can’t use the less expensive (front-line) drug?



A: With step therapy, more expensive brand-name drugs are usually covered as a back-up in the program if:

You’ve already tried the generic drugs covered in your step therapy program

You can’t take a generic drug (for example, because of an allergy)

Your doctor decides, for medical reasons, that you need a brand-name drug If one of these situations applies to you, your doctor can request an override or a “prior authorization” for you, allowing you to take a back-up prescription drug. Once the override is approved, you’ll pay the appropriate copayment for this drug. If the override isn’t approved, you will either have to pay full price for the back-up drug or take an alternative. Q: What are generic drugs? A: Generic equivalent medications have the same chemical makeup and same effect in the body as their original brand-name counterparts. Though generics may have a different name, color, and/or shape, generics have undergone rigorous clinical testing and been approved by the U.S. Food & Drug Administration (FDA) as safe and effective. Unlike manufacturers of brand-name drugs, the companies that make generic drugs don’t need to spend as much money on research and advertising. As a result, generic drugs cost less than the original brand-name drug, and the savings get passed on to you. Q: I sent in a prescription to home delivery and was told I need to use a front-line drug. What happens now? A: Step therapy applies to prescriptions you receive at your local pharmacy, as well as those you order through home delivery, so the same basic process applies. Your doctor may write a prescription for a front-line drug covered by your plan, or your doctor can request an override or a “prior authorization” for you. FAQs about Prior Authorizations

Q: Who decides what prescription drugs require prior authorization? A: The prior authorization program was developed under the guidance and direction of independent licensed doctors, pharmacists and other medical experts. Together with Express Scripts these experts review the most current research on thousands of prescription drugs tested and approved by the FDA as safe and effective and recommend prescription drugs that are appropriate for prior authorization under your plan. Q: What kinds of prescription drugs need a prior authorization in my program? A: Your prior authorization program applies to prescription drugs that:

have dangerous side effects or can be harmful when combined with other drugs

should be used only for certain health conditions

are often misused or abused

are prescribed when less expensive drugs might work better For additional information about Express Scripts’ formulary drugs that require prior authorization, go to www.Express-Scripts.com, under the ‘Manage Prescriptions’ menu, select the ‘Price a Medication’ link or call Express Scripts toll-free at 1 (866) 544-1798.

Q: Why couldn’t I get my original prescription filled at the pharmacy? A: When a prescription needs a prior authorization:



1. Your pharmacist sees a note on the computer system indicating “prior authorization required.” 2. Express Scripts or your pharmacist lets you know that your prescription needs a prior

authorization – which simply means that more information is needed to determine if your plan can cover the medication.

3. You can ask your doctor to call Express Scripts for prior authorization. Only your doctor (or in some cases, your pharmacist) can give Express Scripts the information needed to see if your medication can be covered. The prior authorization phone lines are open 24 hours a day, 7 days a week, so a determination can be made right away. If you learn your prescription requires a prior authorization, you can ask your doctor if there is a different medication you can use that’s covered by your plan. If your doctor does not wish to complete the requirements of the prior authorization program, you have the option of paying the full price for the prescription at your pharmacy. (Note: You will not be reimbursed if you choose this option and the amount you pay will not be applied to your out of pocket maximum).

4. If your doctor (or pharmacist) calls for a prior authorization, an Express Scripts licensed

pharmacist will:

Check your plan’s guidelines to see if your prescription can be covered, and

Determine whether your plan will cover the medication only when it’s used for treating specific FDA approved medical conditions, rather than for other purposes.

Your doctor or pharmacist will be asked questions about your specific condition. If the information provided meets your plan’s requirements, prior authorization will be granted and you will be responsible for paying the applicable copayment at the pharmacy.

Q: I need a prescription filled immediately at a retail pharmacy. What can I do? A: At the pharmacy, your pharmacist may tell you that your prescription requires prior authorization. If this occurs and you need your medication quickly, you can:




Q: Does this program deny me the medication I need? A: No, the program can help you get an effective medication to treat your condition. Through prior authorization, you can receive the right prescription for you that is covered by your benefits. If it’s determined that your plan doesn’t cover the original medication you were prescribed, you can ask your doctor about getting a different medication that is covered. Covered medications will be subject to the applicable copayment. Or, you can choose to fill the original prescription at your pharmacy by paying the full price. Q: What happens if my doctor’s request for prior authorization is denied?


A: Your prescription benefit doesn’t cover certain medications. If you want to file an appeal to have your prescription covered, contact Express Scripts Member Services at 1 (866) 544-1798. Q: I filed an appeal and it was denied. What can I do? A: There are two things you can do:

1. You can talk with your doctor again about prescribing a different medication that is covered by your plan, or

2. You can pay the full price for a medication that isn’t covered by your plan.

Q: I sent a prescription to Express Scripts home delivery pharmacy services, but I was told it needs a prior authorization. What happens now? A: Express Scripts home delivery pharmacy services will try to contact your doctor. You may want to let your doctor know that this call will be coming. If your doctor thinks you need this prescription for your condition, he/she can talk with an Express Scripts home delivery pharmacy services representative about a prior authorization.

FAQs about Controlled Substances

Q: What is a controlled substance or controlled medication?

A: The federal government has categorized a class of medication as having a higher-than-average potential for abuse or addiction. Such medications, known as controlled substances, are divided into categories based on their potential for abuse or addiction. They range from illegal street drugs (Schedule 1, or C1) to medications with decreasing potential for abuse (C2 through C5). Prescriptions containing narcotics or amphetamines are often classified as C2, since they have a relatively high potential for abuse or addiction.

Q: Are there any drugs prohibited from mailing? If so, which ones? A. There are some specific categories of medications that cannot be mailed or may require specific delivery restrictions. Some medications, such as pain relief or sleep agents, are not classified as maintenance (although they may be for your treatment). You can continue filling these types of prescriptions at your local retail pharmacy. If you have specific questions about your medication, you can call Express Scripts Member Services at 1 (866) 544-1798. Q. Can I receive medications that are classified as “controlled substances” through the mail order?

A. You can obtain many controlled substances through the mail order; however, some do require signature upon delivery. Some may also require a new prescription for each fill and have dispensing restrictions that would only allow a certain day supply vs. a 90-day supply. Examples of controlled medications are pain relief and sleep agents. Check with your doctor if you are taking a controlled substance to determine if there are any restrictions and if it would be appropriate for you to fill through the mail order. However, it is important to note that you can continue filling most controlled substances for up to a 31-day supply at the retail pharmacy; you are not required to use mail order when filling these types of prescriptions.

Q: Do controlled substances have special prescribing and dispensing requirements?


A: Yes. Most prescriptions for controlled substances are subject to both federal and state regulations. These regulations define how a prescription can be written, how your doctor can communicate it to a pharmacist, and how many times it can be refilled, among other aspects. For example, many controlled substances can only be refilled up to 6 months from the date of the original prescription, and medications with a higher potential for abuse (C2) cannot be refilled at all. All pharmacies, whether retail or home delivery, are subject to these regulations.

For more information about controlled substances and New Hampshire regulations regarding them, please contact your provider or Express Scripts Member Services at 1 (866) 544-1798.

CRP16_2122

Now that you’ve enrolled in a Medicare Part D plan, the Centers for Medicare & Medicaid

Services (CMS) requires that Express Scripts Medicare send you certain plan materials. This

Evidence of Coverage includes information on standard rules and processes for a Medicare

Part D prescription drug plan program. However, there may be situations where the plan rules

as outlined here differ from those of your former employer or retiree group.

Please be sure to review your other plan materials for plan-specific information or contact

Express Scripts Medicare Customer Service.

Evidence of Coverage: Your Medicare Prescription Drug Coverage as a

Member of Express Scripts Medicare (PDP)

This document provides the details about your Medicare prescription drug coverage from

January 1 – December 31, 2017. It explains how to get coverage for the prescription drugs you need.

This is an important legal document. Please keep it in a safe place.

This plan, Express Scripts Medicare® (PDP), is offered by Medco Containment Life Insurance Company

or Medco Containment Insurance Company of New York (for employer plans domiciled in New York).

(When this Evidence of Coverage says “we,” “us” or “our,” it means Medco Containment Life Insurance

Company or Medco Containment Insurance Company of New York (for employer plans domiciled in New

York). When it says “plan” or “our plan,” it means Express Scripts Medicare.)

Express Scripts Medicare (PDP) is a prescription drug plan with a Medicare contract.

Enrollment in Express Scripts Medicare depends on contract renewal.

Express Scripts Medicare Customer Service:

For more help or information, please call Express Scripts Medicare Customer Service at the number

on the back of your member ID card (TTY users call: 1.800.716.3231) or go to our plan website at

http://www.Express-Scripts.com. Calls to Customer Service are free. Customer Service is available

24 hours a day, 7 days a week. Customer Service has free language interpreter services available for

non-English speakers. This information is available in braille. Please contact Customer Service at the

numbers above if you need plan information in another format.

This information is available for free in other languages. Please contact Customer Service at the numbers on

the back of your member ID card for additional information. Customer Service is available 24 hours a day,

7 days a week. Esta información está disponible sin cargo en otros idiomas. Comuníquese con el Servicio de

atención al cliente de Express Scripts Medicare llamando a los números que figuran al dorso de su tarjeta de

identificación de miembro para obtener información adicional. El Servicio de atención al cliente está

disponible las 24 horas, los 7 días de la semana.

Benefits, premium and/or copayments/coinsurance may change on January 1 of each year. The formulary

and/or pharmacy network may change at any time. You will receive notice when necessary. Limitations,

copayments and restrictions may apply. E00SOS7A

January 1 – December 31, 2017

2017 Evidence of Coverage for Express Scripts Medicare

Table of Contents 2

2017 Evidence of Coverage

Table of Contents

Chapter 1. Getting started as a member of Express Scripts Medicare ............................................. 5

Tells what it means to be in a Medicare prescription drug plan and how to use this document. Tells

about materials we will send you, your plan premium, your member ID card and your membership.

SECTION 1 Introduction ............................................................................................................. 5

SECTION 2 What makes you eligible to be a plan member? .................................................. 6

SECTION 3 What other materials will you get from us? ......................................................... 7

SECTION 4 Your monthly premium for Express Scripts Medicare ....................................... 8

SECTION 5 Please keep your plan membership record up to date....................................... 10

SECTION 6 We protect the privacy of your personal health information ........................... 11

SECTION 7 How other insurance works with our plan ......................................................... 11

Chapter 2. Important phone numbers and resources ...................................................................... 12

Tells you how to get in touch with our plan, Express Scripts Medicare, and with other organizations

including Medicare, Social Security and programs that help people pay for their prescription drugs.

Contact information for these organizations is located in the Appendix.

SECTION 1 Express Scripts Medicare contacts (how to contact us, including how

to reach Express Scripts Medicare Customer Service at the plan) ......................... 12

SECTION 2 Medicare (how to get help and information directly from

the Federal Medicare program)............................................................................... 15

SECTION 3 State Health Insurance Assistance Program (free help, information

and answers to your questions about Medicare) ..................................................... 16

SECTION 4 Quality Improvement Organizations (paid by Medicare to check on the

quality of care for people with Medicare) .............................................................. 16

SECTION 5 Social Security ....................................................................................................... 16

SECTION 6 Medicaid (a joint Federal and state program that helps with medical costs

for some people with limited income and resources) ............................................. 17

Chapter 3. Using the plan’s coverage for your Part D prescription drugs ..................................... 18

Explains rules you need to follow when you get your Part D drugs. Tells how to find out which

drugs are covered or not covered, what type of restrictions may apply to coverage, and where to get

your prescriptions filled. Tells about the plan's programs for drug safety and managing medications.

SECTION 1 Introduction ........................................................................................................... 18

SECTION 2 Fill your prescription at a network pharmacy or through the plan’s

home delivery service............................................................................................ 19

SECTION 3 The plan’s Drug List ............................................................................................. 22

SECTION 4 There are restrictions on coverage for some drugs ............................................ 23

SECTION 5 What if one of your drugs is not covered in the

way you’d like it to be covered? .......................................................................... 25

SECTION 6 What if your coverage changes for one of your drugs? ..................................... 27


Table of Contents 3

SECTION 7 What types of drugs are not covered by the plan? ............................................. 28

SECTION 8 Show your member ID card when you fill a prescription ................................. 29

SECTION 9 Part D drug coverage in special situations ......................................................... 29

SECTION 10 Programs on drug safety and managing medications ....................................... 31

Chapter 4. Paying for your Part D prescription drugs .................................................................... 33

Tells about the four stages of drug coverage for a standard Medicare Part D plan and their effect on

what you pay. Tells about the Medicare Coverage Gap Discount Program, the Part D-IRMAA, the

late enrollment penalty (LEP) and programs to help you pay for your prescription drugs.


SECTION 2 What you pay for a drug depends on the plan selected by your

former employer or your retiree group and which drug payment stage

you are in when you get the drug ........................................................................ 34

SECTION 3 We will send you a Part D Explanation of Benefits (Part D EOB) that explains

payments for your drugs and which payment stage you are in ........................ 35

SECTION 4 If the Deductible stage applies to your former employer or your retiree group

plan, you pay the full cost of your drugs during this stage ............................... 36

SECTION 5 During the Initial Coverage stage, the plan pays its share

of your drug costs and you pay your share ......................................................... 36

SECTION 6 Refer to your other plan materials to see what you pay and what the plan

pays during the Coverage Gap stage................................................................... 38

SECTION 7 During the Catastrophic Coverage stage, the plan pays most

of the cost for your drugs ..................................................................................... 41

SECTION 8 What you pay for vaccinations covered by Part D depends

on how and where you get them .......................................................................... 42

SECTION 9 Do you have to pay the Part D late enrollment penalty (LEP)? ....................... 43

SECTION 10 Do you have to pay an extra Part D amount because of your income? ........... 45

SECTION 11 Information about programs to help people pay

for their prescription drugs……………………………………………...……...46

Chapter 5. Asking us to pay our share of the costs for covered drugs............................................. 50

Describes what you need to do when you want to ask us to pay you back for our share of the cost.

SECTION 1 Situations in which you should ask us to pay our share

of the cost of your covered drugs ......................................................................... 50

SECTION 2 How to ask us to pay you back............................................................................. 51

SECTION 3 We will review your request for payment and say yes or no ............................. 52

SECTION 4 Other situations in which you should save your receipts and

send copies to us .................................................................................................... 52

Chapter 6. Your rights and responsibilities....................................................................................... 54

Explains the rights and responsibilities you have as a member of our plan. Tells what you can do if

you think your rights are not being respected.

SECTION 1 Our plan must honor your rights as a member ................................................. 54

SECTION 2 You have some responsibilities as a member of the plan ................................... 58


Table of Contents 4

Chapter 7. What to do if you have a problem or complaint

(coverage decisions, appeals, complaints) ....................................................................... 60

Explains how to ask for coverage decisions, make appeals and ask for exceptions if you're denied

coverage for a drug. It also explains how to make complaints about quality of care, customer service

and other concerns.

Background


SECTION 2 You can get help from government organizations that are not

connected with us .................................................................................................. 60

SECTION 3 To deal with your problem, which process should you use? ............................. 61

Coverage decisions and appeals

SECTION 4 A guide to the basics of coverage decisions and appeals.................................... 62

SECTION 5 Your Part D prescription drugs: How to ask for a coverage decision

or make an appeal ................................................................................................. 63

SECTION 6 Taking your appeal to Level 3 and beyond ......................................................... 73

Making complaints

SECTION 7 How to make a complaint about quality of care, waiting times,

customer service or other concerns ..................................................................... 74

Chapter 8. Ending your membership in this plan............................................................................. 77

Tells when and how you can end your membership in the plan. Explains situations in which our

plan is required to end your membership.


SECTION 2 When can you end your membership in this plan? ........................................... 77

SECTION 3 How do you end your membership in this plan? ............................................... 79

SECTION 4 Until your membership ends, you must keep getting your drugs

through this plan...................................................................................................79

SECTION 5 Express Scripts Medicare must end your membership in certain situations .. 79

Chapter 9. Legal notices ...................................................................................................................... 81

Includes notices about governing law and about nondiscrimination.

SECTION 1 Notice about governing law .................................................................................. 81

SECTION 2 Notice about nondiscrimination .......................................................................... 81

SECTION 3 Notice about Medicare Secondary Payer subrogation rights ........................... 81

Chapter 10. Definitions of important words........................................................................................ 82

Explains key terms used in this document.

Appendix Important phone numbers and resources….....………..………..………....................…I

Includes: Contact information for AIDS Drug Assistance Programs (ADAPs), State Health Insurance

Assistance Programs (SHIPs), Quality Improvement Organizations (QIOs), State Medicaid Offices

and State Pharmaceutical Assistance Programs (SPAPs).


Chapter 1: Getting started as a member of Express Scripts Medicare 5

Chapter 1. Getting started as a member of Express Scripts Medicare

SECTION 1 Introduction

Section 1.1 You are enrolled in Express Scripts Medicare, which is a Medicare prescription

drug plan

Your former employer or your retiree group has chosen to provide your Medicare prescription drug

coverage through our plan, Express Scripts Medicare.

There are different types of Medicare plans. Express Scripts Medicare is a Medicare prescription drug

plan (PDP). Like all Medicare plans, this Medicare prescription drug plan is approved by Medicare and

run by a private company.

Section 1.2 What is the Evidence of Coverage about?

This Evidence of Coverage tells you how to get your Medicare prescription drug coverage through our

plan. It explains your rights and responsibilities and what is covered. The words “coverage” and “covered

drugs” refer to the prescription drug coverage available to you as a member of Express Scripts Medicare.

It’s important for you to learn what the plan’s rules are and what coverage is available to you. We encourage

you to set aside some time to look through this Evidence of Coverage.

If you are confused or concerned or just have a question, please contact Express Scripts Medicare Customer

Service (contact information is listed on the back of your member ID card).

Section 1.3 Legal information about the Evidence of Coverage

It’s part of our contract with you

This Evidence of Coverage is part of our contract with you about how Express Scripts Medicare covers your

care. Other parts of this contract include your eligibility record, the 2017 Formulary (List of Covered

Drugs), your Benefit Overview, your Annual Notice of Changes packet and any notices you receive from us

about changes to your coverage or conditions that affect your coverage. These notices are sometimes called

“riders” or “amendments.”

The contract is in effect for months in which you are enrolled in Express Scripts Medicare between

January 1, 2017, and December 31, 2017.

Each calendar year, Medicare allows us to make changes to the plans that we offer. This means we can

change the costs and benefits of Express Scripts Medicare after December 31, 2017. We can also choose to

stop offering the plan, or to offer it in a different service area, after December 31, 2017.

Medicare must approve our plan each year

Medicare (the Centers for Medicare & Medicaid Services, or CMS) must approve Express Scripts Medicare

each year. You can continue to get Medicare coverage as a member of our plan only as long as your former

employer or your retiree group chooses to continue to offer the plan for the year in question and CMS

renews its approval of the plan.



SECTION 2 What makes you eligible to be a plan member?

Section 2.1 Your eligibility requirements

You are eligible for membership in our plan as long as:

You live in our geographic service area (Section 2.3 below describes our service area).

You are entitled to Medicare Part A and/or enrolled in Medicare Part B (Section 2.2 tells you about

Medicare Part A and Medicare Part B).

You are a United States citizen or are lawfully present in the United States.

You qualify for coverage from your former employer or your retiree group.

Section 2.2 What are Medicare Part A and Medicare Part B?

Because you meet the requirements noted above in the previous section, you will receive prescription drug

coverage (sometimes called Medicare Part D) through this plan. Express Scripts Medicare (PDP) is a

prescription drug plan with a Medicare contract. This document and other plan materials you have received,

such as the Benefit Overview or Annual Notice of Changes, describe that coverage.

When you originally signed up for Medicare, you received information about how to get Medicare Part A

and Medicare Part B. Remember:

Medicare Part A generally helps cover services provided by institutional providers such as hospitals

(for inpatient services), skilled nursing facilities or home health agencies.

Medicare Part B is for most other medical services (such as physicians’ services and other outpatient

services) and certain items (such as durable medical equipment and supplies).

Section 2.3 Here is the plan service area for Express Scripts Medicare

Although Medicare is a Federal program, Express Scripts Medicare is available only to individuals who

qualify for coverage from their former employer or retiree group and live in our plan service area. To stay

a member of our plan, you must continue to reside in the plan service area. Our service area includes all

50 states, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana

Islands and American Samoa.

If you plan to move, please contact your group benefits administrator.

It is also important that you call Social Security if you move or change your mailing address. You can find

phone numbers for Social Security in Chapter 2, Section 5.

Section 2.4 U.S. Citizen or Lawful Presence

A member of a Medicare prescription drug plan must be a U.S. citizen or lawfully present in the United

States. Medicare will notify Express Scripts Medicare if you are not eligible to remain a member on this

basis. Express Scripts Medicare must disenroll you if you do not meet this requirement.



SECTION 3 What other materials will you get from us?

Section 3.1 Your member ID card: Use it to get all covered prescription drugs

While you are a member of our plan, you must use your member ID card for our plan for prescription drugs

you get at network pharmacies. Below is a sample member ID card to show you what yours may look like.

If you are an existing member, your card may look slightly different.

Please carry your card with you at all times and remember to show your card when you get covered drugs. If

your member ID card is damaged, lost or stolen, call Customer Service right away and we will send you a

new card. (Phone numbers for Customer Service are listed on the back of your member ID card.)

You may need to use your red, white and blue Medicare card to get covered medical care and services under

Original Medicare.

Section 3.2 The Pharmacy Directory: Your guide to pharmacies in our network

How do you find participating network pharmacies?

Our Pharmacy Directory gives you a list of the retail network pharmacies closest to you — that means the

pharmacies in your area that have agreed to fill covered prescriptions for our plan members — as well as

other pharmacies (such as long-term care pharmacies) in our network.

Why do you need to know about network pharmacies?

With few exceptions, you must get your prescriptions filled at one of our network pharmacies if you want

our plan to cover (help you pay for) them. There may be changes to our network of pharmacies for 2017.

The Pharmacy Directory will tell you which pharmacies are in our network and, if available in your plan,

which network pharmacies offer preferred cost-sharing. Preferred cost-sharing may be lower than the

standard cost-sharing offered by other network pharmacies.

If you don’t have a Pharmacy Directory, you can get a copy from Customer Service (phone numbers are

listed on the back of your member ID card). At any time, you can call Customer Service to get up-to-date

information about changes in the pharmacy network. You can also find this information on our website at

http://www.Express-Scripts.com.

Section 3.3 The plan’s 2017 Formulary (List of Covered Drugs)

The plan has a Formulary (List of Covered Drugs) for the 2017 plan year, which we will send to you. We

call it the “Drug List” for short. It tells which commonly used Part D prescription drugs are covered by



Express Scripts Medicare. The drugs on this list are selected by the plan with the help of a team of doctors

and pharmacists. The Express Scripts Medicare Drug List meets the requirements set by Medicare and has

been approved.

The Drug List also tells you if there are any rules that restrict coverage for covered drugs, and it includes

information for the covered drugs that are most commonly used by our members. However, we cover

additional Part D drugs that are not included in the printed Drug List. If one of your Part D drugs is not on

the Drug List, you should contact Customer Service to find out if we cover it. To get the most complete and

current information about which drugs are covered, call Customer Service (phone numbers are listed on the

back of your member ID card).

Section 3.4 The Part D Explanation of Benefits (the “Part D EOB”): A summary of payments made

for your Part D prescription drugs

When you use your Part D prescription drug benefits, we will send you a summary to help you understand

and keep track of payments for your Part D prescription drugs. This summary is called the Part D

Explanation of Benefits (or the Part D EOB).

The Part D EOB tells you the total amount you, or others on your behalf, have spent on your Part D

prescription drugs and the total amount we have paid for each of your Part D prescription drugs during the

month. Chapter 4 gives more information about the Part D EOB and how it can help you keep track of your

drug coverage.

A Part D EOB summary is also available upon request. To get a copy, please contact Customer Service at

the phone numbers listed on the back of your member ID card. In addition to receiving your Part D EOB in

the mail, you may view a copy by visiting our website, http://www.Express-Scripts.com.

SECTION 4 Your monthly premium for Express Scripts Medicare

Section 4.1 Your plan premium

Your coverage is provided through a contract with your former employer or your retiree group. Your group

benefits administrator determines how your plan premium is paid. If you have questions about your plan

premium, please contact your group benefits administrator for more information.

If your former employer or your retiree group charges you a plan premium or a portion of the plan premium,

you are required to pay the premium according to their instructions.

If your former employer or your retiree group has not received your plan premium when it is due, a notice

will be sent to you telling you that plan membership will end if they do not receive your plan premium

within the grace period determined by your former employer or retiree group.

If your membership is ended due to nonpayment of premiums, you will have coverage under Original

Medicare. At the time your membership is ended, premiums that have not been paid may still be owed

to your former employer or your retiree group. If this occurs and you want to enroll again in our plan,

contact your group benefits administrator. Any past-due premiums may need to be paid before you can be

re-enrolled.

If you think your membership has been wrongfully ended, please contact your group benefits administrator

to determine what steps you need to follow to have your coverage reinstated. Chapter 7, Section 7 tells



how to make a complaint. In addition, you must continue to pay any applicable Medicare Part B premium

(unless your Part B premium is paid for you by Medicaid or another third party).

In some situations, your plan premium could be less

There are programs to help people with limited resources pay for their drugs. These include the Extra Help

and State Pharmaceutical Assistance Programs. Chapter 4 tells more about these programs. If you qualify,

enrolling in one or both of these programs might lower your monthly plan premium.

If you are already enrolled and getting help from one of these programs, some of the information in your

other plan documents may not apply to you. We will send you a notice called “Important Information for

Those Who Receive Extra Help Paying for Their Prescription Drugs” (Low Income Subsidy (LIS) Rider),

which tells you about your drug coverage. If you don’t have this notice, please call Customer Service and

ask for the LIS Rider. Phone numbers for Customer Service are listed on the back of your member ID card.

In some situations, your plan premium could be more

In some situations, your plan premium could be more than the amount charged by your former employer or

retiree group. These situations are described below.

Some members are required to pay a late enrollment penalty (LEP) because they did not join a

Medicare drug plan when they first became eligible or because they had a continuous period of

63 days or more when they didn’t have “creditable” prescription drug coverage. (“Creditable” means

the drug coverage is expected to pay, on average, at least as much as Medicare’s standard

prescription drug coverage.) For these members, the LEP is added to the plan’s monthly premium.

o If you are required to pay the LEP, the amount of your penalty depends on how long you

waited before you enrolled in drug coverage or how many months you were without drug

coverage after you became eligible. Chapter 4, Section 9 explains the LEP.

o If you have an LEP and do not pay it, you could be disenrolled from the plan.

Many members are required to pay other Medicare premiums

In addition to paying your monthly Part D plan premium, some members may be required to pay other

Medicare premiums, possibly for Medicare Part A or Part B.

Some people pay an extra amount for Part D because of their yearly income. This is known as the Part D

Income-Related Monthly Adjustment Amount, also known as Part D-IRMAA. If your income is greater

than $85,000 for an individual (or married individuals filing separately) or greater than $170,000 for

married couples, you must pay an extra amount directly to the government (not your Medicare plan) for

your Medicare Part D coverage.

If you are required to pay the extra amount and you do not pay it, you will be disenrolled

from the plan and you will lose your prescription drug coverage.

If you have to pay an extra amount, Social Security, not your Medicare plan, will send you a

letter telling you what that extra amount will be.

For more information about Part D premiums based on income, go to Chapter 4, Section 10. You

can also visit http://www.medicare.gov on the web or call 1.800.MEDICARE (1.800.633.4227),

24 hours a day, 7 days a week. TTY users should call 1.877.486.2048. Or you may call Social

Security at 1.800.772.1213. TTY users should call 1.800.325.0778.

Your copy of Medicare & You 2017 gives information about the Medicare premiums in the section called

“2017 Medicare Costs.” This explains how the Part D premium differs for people with different incomes.

Everyone with Medicare receives a copy of Medicare & You each year in the fall. Those new to Medicare



receive it within a month after first signing up. You can also download a copy of Medicare & You 2017 from

the Medicare website (http://www.medicare.gov). Or you can order a printed copy by phone at

1.800.MEDICARE (1.800.633.4227), 24 hours a day, 7 days a week. TTY users should call 1.877.486.2048.

Section 4.2 Can your former employer or your retiree group change your monthly plan premium

during the year?

No. Your former employer or your retiree group is not allowed to change the amount it charges for the

plan’s monthly plan premium during the year. If the monthly plan premium changes for next year, you will

be notified of the change in the fall and the change will take effect on January 1.

However, in some cases, the part of the premium that you have to pay can change during the year. This

happens if you become eligible for, or lose your eligibility for, the “Extra Help” program during the year. If

a member qualifies for Extra Help with his or her prescription drug costs, the Extra Help program will pay

all or part of the member’s monthly plan premium. A member who loses his or her eligibility during the year

will need to start paying his or her full monthly premium. You can find out more about the Extra Help

program in Chapter 4, Section 11.

SECTION 5 Please keep your plan membership record up to date

Section 5.1 How to help make sure that we have accurate information about you

Your membership record has information from your eligibility record, including your address and telephone

number. It shows your specific plan coverage.

The pharmacists in the plan’s network need to have correct information about you. These network

providers use your membership record to know what drugs are covered and the cost-sharing amounts

for you. Because of this, it is very important that you help us keep your information up to date.

Let us know about these changes:

Changes to your name, your address or your phone number

Changes in any other medical or drug insurance coverage you have (such as from your employer,

your spouse’s employer, workers’ compensation or Medicaid)

If you have any liability claims, such as claims from an automobile accident

If you have been admitted to a nursing home

If your designated responsible party (such as a caregiver) changes

If any of this information changes, please let us know by calling either your group benefits administrator or

Customer Service (phone numbers are listed on the back of your member ID card).

It is also important to contact Social Security if you move or change your mailing address. You can find

phone numbers for Social Security in Chapter 2, Section 5.

Read over the information we send you about any other insurance coverage you have

That’s because we must coordinate any other coverage you have with your benefits under our plan. (For

more information about how our coverage works when you have other insurance, see Section 7 in this

chapter.)

Once each year, we will send you a letter that lists any other medical or drug insurance coverage that we

know about. Please read over this information carefully. If it is correct and complete, you don’t need to do

anything. If the information is incorrect or incomplete, or if you have other coverage that is not listed, please



call the number noted in the letter you receive to provide us with the correct information to coordinate your

benefits. If you have questions about who pays first, or you need to update your other insurance information,

call Medicare’s Benefits Coordination & Recovery Center (BCRC) toll free at 1.855.798.2627, Monday

through Friday, 8:00 a.m. to 8:00 p.m., Eastern Time. TTY users should call 1.855.797.2627.

SECTION 6 We protect the privacy of your personal health information

Section 6.1 We make sure that your health information is protected

Federal and state laws protect the privacy of your medical records and personal health information. We

protect your personal health information as required by these laws.

For more information about how we protect your personal health information, please go to Chapter 6,

Section 1.4.

SECTION 7 How other insurance works with our plan

Section 7.1 Which plan pays first when you have other insurance?

When you have other insurance (like employer group health coverage in addition to this plan), there are

rules set by Medicare that decide whether our plan or your other insurance pays first. The insurance that

pays first is called the “primary payer” and pays up to the limits of its coverage. The one that pays second,

called the “secondary payer,” only pays if there are costs left uncovered by the primary coverage. The

secondary payer may not pay all of the uncovered costs.

These rules apply for employer or retiree group health plan coverage (other coverage outside of this plan):

If you have retiree coverage, Medicare pays first.

If your group health plan coverage is based on your or a family member’s current employment, who

pays first depends on your age, the number of people employed by your employer and whether you

have Medicare based on age, disability or End-Stage Renal Disease (ESRD):

o If you’re under 65 and disabled and you or your family member is still working, your plan pays

first if the employer has 100 or more employees or at least one employer in a multiple employer

plan has more than 100 employees.

o If you’re over 65 and you or your spouse is still working, the plan pays first if the employer has

20 or more employees or at least one employer in a multiple employer plan has more than 20

employees.

o If you have Medicare because of ESRD, your group health plan will pay first for the first

30 months after you become eligible for Medicare.

These types of coverage usually pay first for services related to each type:

No-fault insurance (including automobile

insurance)

Liability (including automobile insurance)

Black lung benefits

Workers’ compensation

Medicaid and TRICARE never pay first for Medicare-covered services. They only pay after Medicare,

employer group health plans and/or Medigap have paid.

If you have other insurance, tell your doctor, hospital and pharmacy. If you have questions about who pays

first, or you need to update your other insurance information, call Customer Service (phone numbers are

listed on the back of your member ID card). You may need to give your plan member ID number to your

other insurers (once you have confirmed their identity) so your bills are paid correctly and on time.


Chapter 2: Important phone numbers and resources 12

Chapter 2. Important phone numbers and resources

SECTION 1 Express Scripts Medicare contacts

(how to contact us, including how to reach Express Scripts Medicare

Customer Service at the plan)

How to contact Express Scripts Medicare Customer Service

For assistance with claims, billing or member ID card questions, please call or write to Express Scripts

Medicare Customer Service. We will be happy to help you.

Method Customer Service – Contact Information

CALL The phone numbers for Express Scripts Medicare Customer Service are listed

on the back of your member ID card.

WRITE Express Scripts Medicare

P.O. Box 14570

Lexington, KY 40512

WEBSITE http://www.Express-Scripts.com

How to contact us when you are asking for a coverage decision or an appeal about your Part D

prescription drugs

A coverage decision is a decision we make about your benefits and coverage or about the amount we will

pay for your Part D prescription drugs. For more information on asking for coverage decisions about your

Part D prescription drugs, see Chapter 7.

An appeal is a formal way of asking us to review and change a coverage decision we have made. For

more information on making an appeal about your Part D prescription drugs, see Chapter 7. You may

call us if you have questions about our coverage decision and appeals processes.

There are two types of coverage decisions and appeals: administrative and clinical. An administrative

coverage decision or appeal occurs when the issue involves a decision about whether a medication is

covered or not and at what cost-sharing amount. A clinical coverage decision or appeal occurs when the

issue involves a decision about a restriction on a specific medication.



Method Initial Clinical Coverage Reviews (Including Prior Authorization Requests)

for Part D Prescription Drugs – Contact Information

CALL 1.844.374.7377 (1.844.ESI.PDPS)

Calls to this number are free. Our business hours are 24 hours a day, 7 days a week.

TTY 1.800.716.3231

This number requires special telephone equipment and is only for people who have

difficulties with hearing or speaking. Calls to this number are free. Our business

hours are 24 hours a day, 7 days a week.

FAX 1.877.328.9799

WRITE Express Scripts

Attn: Medicare Reviews

P.O. Box 66571

St. Louis, MO 63166-6571


Method Clinical Appeals for Part D Prescription Drugs – Contact Information

CALL 1.844.374.7377 (1.844.ESI.PDPS) Calls to this number are free. Our business hours are Monday through Friday,

8:00 a.m. to 8:00 p.m., Central Time.

TTY 1.800.716.3231



hours are Monday through Friday, 8:00 a.m. to 8:00 p.m., Central Time.

FAX 1.877.852.4070


Attn: Medicare Clinical Appeals

P.O. Box 66588

St. Louis, MO 63166-6588


Method Administrative Coverage Reviews and Appeals for Part D

Prescription Drugs – Contact Information

CALL 1.800.413.1328

Calls to this number are free. Our business hours are Monday through Friday,

8:00 a.m. to 6:00 p.m., Central Time.

TTY 1.800.716.3231



hours are Monday through Friday, 8:00 a.m. to 6:00 p.m., Central Time.

FAX 1.877.328.9660


Attn: Medicare Administrative Appeals

P.O. Box 66587

St. Louis, MO 63166-6587




How to contact us when you are making a complaint about the quality of care you have received,

waiting times, customer service or other concerns

You can make a complaint about us or one of our network pharmacies, including a complaint about the

quality of your care. This type of complaint does not involve coverage or payment disputes. (If your

problem is about the plan’s coverage or payment, you should look at the previous section about making

an appeal.) For more information on making a complaint, see Chapter 7.

Method Express Scripts Contact Information for Filing a Complaint

CALL The phone numbers for Express Scripts Medicare Customer Service are listed on the

back of your member ID card.

TTY 1.800.716.3231



hours are 24 hours a day, 7 days a week.

FAX 1.614.907.8547

WRITE Express Scripts Medicare

Attn: Grievance Resolution Team

P.O. Box 3610

Dublin, OH 43016-0307

MEDICARE

WEBSITE You can submit a complaint about Express Scripts Medicare directly to Medicare.

To submit an online complaint to Medicare, go to

http://www.medicare.gov/MedicareComplaintForm/home.aspx.

Where to send a request asking us to pay for our share of the cost of a drug you have received

The coverage determination process includes determining requests that ask us to pay for our share of the

costs of a drug that you have received. For more information on situations in which you may need to ask

the plan for reimbursement or to pay a bill you have received from a provider, see Chapter 5.

Please note: If you send us a payment request and we deny any part of your request, you can appeal our

decision. See Chapter 7 for more information.

Method Express Scripts Contact Information for Payment Requests

CALL The phone numbers for Express Scripts Medicare Customer Service are

listed on the back of your member ID card.

FAX 1.608.741.5483


ATTN: Medicare Part D

P.O. Box 14718

Lexington, KY 40512-4718




SECTION 2 Medicare

(how to get help and information directly from the Federal Medicare program)

Medicare is the Federal health insurance program for people 65 years of age or older, some people under

age 65 with disabilities and people with End-Stage Renal Disease, also called ESRD (permanent kidney

failure requiring dialysis or a kidney transplant).

The Federal agency in charge of Medicare is the Centers for Medicare & Medicaid Services (sometimes

called “CMS”). This agency contracts with Medicare prescription drug plans, including our plan.

Method Medicare – Contact Information

CALL 1.800.MEDICARE, or 1.800.633.4227

Calls to this number are free, 24 hours a day, 7 days a week.

TTY 1.877.486.2048


difficulties with hearing or speaking. Calls to this number are free.

WEBSITE http://www.medicare.gov

This is the official government website for Medicare. It gives you up-to-date

information about Medicare and current Medicare issues. It also has information

about hospitals, nursing homes, physicians, home health agencies and dialysis

facilities. It includes booklets you can print directly from your computer. You can

also find Medicare contacts in your state.

The Medicare website also has detailed information about your Medicare eligibility

and enrollment options with the following tools:

Medicare Eligibility Tool: Provides Medicare eligibility status information.

Medicare Plan Finder: Provides personalized information about available

Medicare prescription drug plans, Medicare health plans and Medigap (Medicare

Supplement Insurance) policies in your area. These tools provide an estimate of

what your out-of-pocket costs might be in different Medicare plans.

You can also use the website to tell Medicare about any complaints you have about

Express Scripts Medicare:

Tell Medicare about your complaint: You can submit a complaint about

Express Scripts Medicare directly to Medicare. To submit a complaint to

Medicare, go to http://www.medicare.gov/MedicareComplaintForm/home.aspx.

Medicare takes your complaints seriously and will use this information to help

improve the quality of the Medicare program.

If you don’t have a computer, your local library or senior center may be able to help

you visit this website using its computer. Or, you can call Medicare and tell them

what information you are looking for. They will find the information on the website,

print it out and send it to you. (You can call Medicare at 1.800.MEDICARE

(1.800.633.4227), 24 hours a day, 7 days a week. TTY users should call

1.877.486.2048.)



SECTION 3 State Health Insurance Assistance Program

(free help, information and answers to your questions about Medicare)

The State Health Insurance Assistance Program (SHIP) is a government program with trained counselors

in every state. Please refer to the SHIP listing located in the Appendix to find information about the

SHIP in your state.

A SHIP is independent (not connected with any insurance company or health plan). It is a state program

that gets money from the Federal government to give free local health insurance counseling to people

with Medicare.

SHIP counselors can help you with your Medicare questions or problems. They can help you understand

your Medicare rights, help you make complaints about your medical care or treatment and help you

straighten out problems with your Medicare bills. SHIP counselors can also help you understand your

Medicare plan choices and answer questions about switching plans.

SECTION 4 Quality Improvement Organizations

(paid by Medicare to check on the quality of care for people with Medicare)

There is a designated Quality Improvement Organization (QIO) for serving Medicare beneficiaries in

each state. Please refer to the QIO listing located in the Appendix to find information about the QIO in

your state.

The QIO has a group of doctors and other healthcare professionals who are paid by the Federal

government. This organization is paid by Medicare to check on and help improve the quality of care for

people with Medicare. The QIO is an independent organization. It is not connected with our plan.

You should contact the QIO if you have a complaint about the quality of care you have received. For

example, you can contact the QIO if you were given the wrong medication or if you were given

medications that interact in a negative way.

SECTION 5 Social Security

The Social Security Administration (SSA) is responsible for determining eligibility and handling

enrollment for Medicare. U.S. citizens who are 65 or older, or who have a disability or End-Stage Renal

Disease (ESRD) and meet certain conditions, are eligible for Medicare. If you are already getting Social

Security checks, enrollment into Medicare is automatic. If you are not getting Social Security checks, you

have to enroll in Medicare. Social Security handles the enrollment process for Medicare. To apply for

Medicare, you can call Social Security or visit your local Social Security office.

Social Security is also responsible for determining who has to pay an extra amount for their Part D drug

coverage because they have a higher income. If you have questions after receiving a letter from Social

Security telling you that you have to pay the extra amount, or if your income went down because of a life-

changing event, you can call Social Security to ask for a reconsideration. If you move or change your

mailing address, it is important that you contact Social Security to let them know.



Method Social Security Administration – Contact Information

CALL 1.800.772.1213

Calls to this number are free. The SSA is available from 7:00 a.m. to 7:00 p.m.,

Eastern Time, Monday through Friday.

You can use Social Security’s automated telephone services to get recorded

information and conduct some business 24 hours a day, 7 days a week.

TTY 1.800.325.0778


difficulties with hearing or speaking.

Calls to this number are free. The SSA is available from 7:00 a.m. to 7:00 p.m.,

Eastern Time, Monday through Friday.

WEBSITE http://www.ssa.gov

SECTION 6 Medicaid

(a joint Federal and state program that helps with medical costs for some people with limited

income and resources)

Medicaid is a joint Federal and state government program that helps with medical costs for certain people

with limited incomes and resources. Some people with Medicare are also eligible for Medicaid.

In addition, there are programs offered through Medicaid that help people with Medicare pay their

Medicare costs, such as their Medicare premiums. These “Medicare Savings Programs” help people with

limited income and resources save money each year:

Qualified Medicare Beneficiary (QMB): Helps pay Medicare Part A and Part B premiums and

other cost-sharing (like deductibles, coinsurance and copayments). (Some people with QMB are also

eligible for full Medicaid benefits (QMB+).)

Specified Low-Income Medicare Beneficiary (SLMB): Helps pay Part B premiums. (Some people

with SLMB are also eligible for full Medicaid benefits (SLMB+).)

Qualified Individual (QI): Helps pay Part B premiums.

Qualified Disabled & Working Individuals (QDWI): Helps pay Part A premiums.

To find out more about Medicaid and its programs, contact the Medicaid agency in your state (contact

information is located in the Appendix).


Chapter 3: Using the plan’s coverage for your Part D prescription drugs 18

Chapter 3. Using the plan’s coverage for your Part D prescription drugs

? Did you know there are programs to help people pay for their drugs?

There are programs to help people with limited resources pay for their drugs. These include

Extra Help and State Pharmaceutical Assistance Programs (SPAPs). For more information, see

Chapter 4, Section 11.

Are you currently getting help to pay for your drugs?

If you are in a program that helps pay for your drugs, some information in this Evidence of

Coverage about the costs for Part D prescription drugs may not apply to you. Please review

the notice entitled “Important Information for Those Who Receive Extra Help Paying for Their

Prescription Drugs” (Low Income Subsidy (LIS) Rider), which tells you about your drug

coverage. If you don’t have this insert, please call Customer Service and ask for the LIS Rider.

Phone numbers for Customer Service are listed on the back of your member ID card.


Section 1.1 This chapter explains rules for using this plan’s coverage of Part D drugs

Your Part D prescription drugs are covered under our plan. In addition, Original Medicare (Medicare Part A

and Part B) also covers some drugs:

Medicare Part A covers drugs you are given during Medicare-covered stays in the hospital or in a

skilled nursing facility.

Medicare Part B also provides benefits for some drugs. Part B drugs include certain chemotherapy

drugs, certain drug injections you are given during an office visit and drugs you are given at a

dialysis facility.

To find out more about coverage through Original Medicare, see your Medicare & You handbook.

Section 1.2 Basic rules for the plan’s Part D drug coverage

The plan will generally cover your drugs as long as you follow these basic rules:

You must have a provider (a doctor, dentist or other prescriber) write your prescription.

Your prescriber must either accept Medicare or file documentation with CMS showing that he or she

is qualified to write prescriptions or your Part D claim will be denied. You should ask your

prescribers the next time you call or visit if they meet this condition. If not, please be aware it takes

time for your prescriber to submit the necessary paperwork to be processed.

You generally must use a network pharmacy to fill your prescription. (See Section 2 of this chapter

for more information.)

Your drug is an approved Part D drug.

Your drug must be used for a medically accepted indication. A “medically accepted indication” is a

use of the drug that is either approved by the Food and Drug Administration (FDA) or supported by

certain reference books. (See Section 3 of this chapter for more information.)



SECTION 2 Fill your prescription at a network pharmacy or through the plan’s

home delivery service

Section 2.1 To have your prescription covered, use a network pharmacy

In most cases, your prescriptions are covered only if they are filled at the plan’s network pharmacies.

(See Section 2.5 for information about when we would cover prescriptions filled at out-of-network

pharmacies.) A network pharmacy is a pharmacy that has a contract with the plan to provide your

covered prescription drugs. The term “covered drugs” means all of the Part D prescription drugs that are

covered on the plan’s Drug List.

If your plan includes pharmacies that offer standard cost-sharing and pharmacies that offer preferred cost-

sharing, you may go to either type of network pharmacy to receive your covered prescription drugs. Your

costs may be less at pharmacies with preferred cost-sharing. The Pharmacy Directory will tell you which of

the network pharmacies offer preferred cost-sharing.

Section 2.2 Finding network pharmacies

How do you find a network pharmacy in your area?

To find a network pharmacy, visit our website at http://www.Express-Scripts.com or call Customer

Service (phone numbers are listed on the back of your member ID card). You can also look in your

Pharmacy Directory. If you don’t have a copy of the Pharmacy Directory and you would like one, please

call Customer Service. Choose whatever is easiest for you.

You may go to any of our network pharmacies. However, if your plan includes pharmacies that offer

preferred cost-sharing, your costs may be even less for your covered drugs at one of these pharmacies. If

you switch from one network pharmacy to another and you need a refill of a drug you have been taking, you

can ask either to have a new prescription written by a doctor or to have your prescription transferred to your

new network pharmacy.

The Pharmacy Directory will tell you which, if any, network pharmacies offer preferred cost-sharing.

What if the pharmacy you have been using leaves the network?

If the pharmacy you have been using leaves the plan’s network, you will have to find a new pharmacy that is

in the network. Similarly, if your plan has pharmacies that offer preferred cost-sharing, and your pharmacy

no longer offers preferred cost-sharing even though it’s still in the plan’s network, you may want to switch

to a different pharmacy. To find another network pharmacy in your area, you can get help from Customer

Service (phone numbers are listed on the back of your member ID card) or use the Pharmacy Directory. You

can also find information on our website at http://www.Express-Scripts.com.

What if you need a specialty pharmacy?

Sometimes prescriptions must be filled at a specialty pharmacy. Specialty pharmacies include:

Pharmacies that supply drugs for home infusion therapy.

Pharmacies that supply drugs for residents of a long-term care (LTC) facility. Usually, an LTC

facility (such as a nursing home) has its own pharmacy. If you are in an LTC facility, we must

ensure that you are able to routinely receive your Part D benefits through our network of LTC

pharmacies, which is typically the pharmacy that the LTC facility uses. Residents may get



prescription drugs through the facility’s pharmacy as long as it is part of our network. If your

LTC pharmacy is not in our network, please contact Customer Service.

Pharmacies that serve the Indian Health Service/Tribal/Urban Indian Health Program (not

available in Puerto Rico). Except in emergencies, only Native Americans or Alaska Natives have

access to these pharmacies in our network.

Pharmacies that dispense drugs that are restricted by the FDA to certain locations, or that require

special handling, provider coordination or education on their use. (Note: This scenario should

happen rarely.)

To locate a specialty pharmacy, visit our website at http://www.Express-Scripts.com, call Customer

Service or look in your Pharmacy Directory.

Section 2.3 Using the plan’s home delivery service

For certain kinds of drugs, you can use the plan’s home delivery service. Generally, the drugs provided

through home delivery are drugs that you take on a regular basis for a chronic or long-term medical

condition. The drugs available through our plan’s home delivery service are marked as mail-order drugs

(MO) in our Drug List.

To get order forms and information about filling your prescriptions by mail, either visit our website at

http://www.Express-Scripts.com or call Customer Service at the numbers listed on the back of your

member ID card.

Usually, a home delivery pharmacy order will get to you within 10 days. However, sometimes your home

delivery may be delayed. Make sure you have at least a 14-day supply of medication on hand. If you don’t

have enough, ask your doctor to give you a second prescription for a 30-day supply and fill it at a network

retail pharmacy while you wait for your home delivery supply to arrive. If your home delivery shipment is

delayed, please call Customer Service.

New prescriptions the pharmacy receives directly from your doctor’s office

The pharmacy will automatically fill and deliver new prescriptions it receives from healthcare providers,

without checking with you first, if either:

You used home delivery services with this plan in the previous twelve months, or

You signed up for automatic delivery of all eligible new prescriptions received directly from

healthcare providers. You may request automatic delivery of all new prescriptions now or at any

time by contacting Customer Service. The request for automatic deliveries of new prescriptions

only lasts until the end of the plan year (which is typically the last day of the calendar year), and

you must submit a new request every year and/or each time you change plans.

Please note that not all prescriptions are eligible for automatic delivery. Medications commonly excluded

from the program include those not indicated for chronic use (antibiotics, anti-infectives) or prescribed on

an as-needed basis (pain medications), as well as medications with legal restrictions, supply limitations or

controlled substances.

If you receive a prescription automatically by mail that you do not want, and you were not contacted to see

if you wanted it before it shipped, you may be eligible for a refund.

If you used home delivery in the past and do not want the pharmacy to automatically fill and ship each new

prescription, please contact us by calling Customer Service using the phone numbers on the back of your

member ID card.



If you have never used our home delivery service and/or decide to stop automatic fills of new prescriptions,

Express Scripts will contact you each time it gets a new prescription from a healthcare provider to see if you

want the medication filled and shipped immediately. This will give you an opportunity to make sure that the

pharmacy is delivering the correct drug (including strength, amount and form) and, if necessary, allow you

to cancel or delay the order before you are billed and it is shipped. It is important that you respond each time

you are contacted to let them know what to do with the new prescription and to prevent any delays in

shipping.

To opt out of automatic deliveries of new prescriptions received directly from your healthcare provider’s

office, please contact us by visiting our website at http://www.Express-Scripts.com or by calling Customer

Service at the numbers listed on the back of your member ID card.

Refills on home delivery prescriptions. For refills of your drugs, you may have the option to sign up for an

automatic refill program. Under this program, we will start to process your next refill automatically when

our records show you should be close to running out of your drug. Express Scripts will contact you prior to

shipping each refill to make sure you are in need of more medication, and you can cancel scheduled refills if

you have enough of your medication or if your medication has changed. If you choose not to use our auto

refill program, please contact your pharmacy 17 to 21 days before you think the drugs you have on hand

will run out to make sure your next order is shipped to you in time.

To opt out of our program that automatically prepares home delivery refills, please contact us by visiting our

website at http://www.Express-Scripts.com or by calling Customer Service. You should also provide the

best ways to contact you by calling Customer Service at the numbers listed on the back of your member ID

card. This way, the pharmacy can reach you to confirm your order before shipping.

Section 2.4 How can you get a maintenance supply of drugs?

When you get a maintenance supply of drugs, your cost-sharing amount may be lower. The plan offers two

ways to get a long-term supply of maintenance drugs on our plan’s Drug List. (Maintenance drugs are drugs

that you take on a regular basis for a chronic or long-term medical condition.) You may order this supply

through mail order (see Section 2.3) or at some retail pharmacies.

1. Some retail pharmacies in our network allow you to get a long-term supply of maintenance drugs.

They may accept a lower cost-sharing amount for a long-term supply of maintenance drugs. Other

retail pharmacies may not agree to accept this lower cost-sharing amount. In this case, you will be

responsible for the difference in price. Your Pharmacy Directory tells you which pharmacies in our

network can give you a long-term supply of maintenance drugs. You can also call Customer Service

at the numbers listed on the back of your member ID card for more information.

2. For certain kinds of drugs, you can use the plan’s home delivery service. The drugs available

through our plan’s home delivery service are marked as “MO” drugs in our Drug List. See

Section 2.3 for more information about using our home delivery service.

Section 2.5 When can you use a pharmacy that is not in the plan’s network?

Your prescription may be covered in certain situations

Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a

network pharmacy. Here are the circumstances when we would cover prescriptions filled at an

out-of-network pharmacy:



In a medical emergency. We will cover prescriptions that are filled at an out-of-network pharmacy if the

prescriptions are related to care for a medical emergency or urgently needed care.

When traveling out of the plan’s service area. If you take a prescription drug on a regular basis and you

are going on a trip, be sure to check your supply of the drug before you leave. You may be able to order your

prescription drugs ahead of time through our home delivery pharmacy service. If you are traveling within

the United States and need to fill a prescription because you become ill or you lose or run out of your

covered medications, we will cover prescriptions that are filled at an out-of-network pharmacy if you follow

all other coverage rules. Prior to filling your prescription at an out-of-network pharmacy, call the Customer

Service numbers listed on the back of your member ID card to find out if there is a network pharmacy in the

area where you are traveling. If there are no network pharmacies in that area, Customer Service may be able

to make arrangements for you to get your prescriptions from an out-of-network pharmacy. We cannot pay

for any prescriptions that are filled by pharmacies outside the United States, even for a medical emergency.

To obtain a covered drug in a timely manner. In some cases, you may be unable to obtain a covered drug

in a timely manner within our service area. If there is no network pharmacy within a reasonable driving

distance that provides 24-hour service, we will cover your prescription at an out-of-network pharmacy.

If a network pharmacy does not stock a covered drug. Some covered prescription drugs (including

orphan drugs or other specialty pharmaceuticals) may not be regularly stocked at an accessible network

retail pharmacy or through our home delivery pharmacy service. We will cover prescriptions at an

out-of-network pharmacy under these circumstances.

In these situations, please check first with Express Scripts Medicare Customer Service to see if there is a

network pharmacy nearby. Phone numbers for Customer Service are listed on the back of your member ID

card. You may be required to pay the difference between what you pay for the drug at the out-of-network

pharmacy and the cost that we would cover at an in-network pharmacy.

How do you ask for reimbursement from the plan?

If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than your

normal share of the cost) at the time you fill your prescription. You can ask us to reimburse you for our

share of the cost. (Chapter 5, Section 2.1 explains how to ask the plan to pay you back.)

SECTION 3 The plan’s Drug List

Section 3.1 The Drug List tells which commonly used Part D drugs are covered

The plan has a 2017 Formulary (List of Covered Drugs). In this Evidence of Coverage, we call it the Drug

List for short. The drugs on this list are selected by the plan with the help of a team of doctors and

pharmacists. The list meets the requirements set by Medicare and has been approved.

The drugs on the Drug List are only those covered under Medicare Part D (earlier in this chapter,

Section 1.1 explains about Part D drugs).

We will generally cover a Part D drug as long as you follow the other coverage rules explained in this

chapter and the use of the drug is a medically accepted indication. A “medically accepted indication” is a

use of the drug that is either:



approved by the Food and Drug Administration (FDA). (That is, the FDA has approved the drug for the

diagnosis or condition for which it is being prescribed.)

– or – supported by certain reference books. (These reference books are the American Hospital

Formulary Service Drug Information, the DRUGDEX Information System and the USPDI or its

successor, and for cancer, the National Comprehensive Cancer Network and Clinical Pharmacology or

their successors.)

The Drug List includes both brand-name and generic drugs

A generic drug is a prescription drug that has the same active ingredients as the brand-name drug. Generally,

it works just as well as the brand-name drug and usually costs less. There are generic drug substitutes

available for many brand-name drugs.

Your specific plan may also cover certain over-the-counter drugs. Some over-the-counter drugs are less

expensive than prescription drugs and work just as well. To understand your plan’s specific coverage,

review your Benefit Overview or call Customer Service.

What is not on the Drug List?

The plan does not cover all prescription drugs. In some cases, the law does not allow any Medicare plan to

cover certain types of drugs (for more about this, see Section 7.1 in this chapter).

As mentioned previously, the Drug List does not contain all drugs covered by this plan. The Drug List

contains the Part D drugs that are most commonly used by our members. If your drug is not included in the

Drug List, you can call Customer Service to find out if we cover it.

Section 3.2 How can you find out if a specific Part D drug is covered by the plan?

You have two ways to find out:

1. Check the most recent Drug List we sent you in the mail. Please note: The Drug List we

send to you includes information for the covered drugs that are highly utilized (or most

commonly used) by our members. However, we cover additional Part D drugs that are not

included in the printed Drug List.

2. Call Customer Service to find out if a particular drug is covered by the plan.

SECTION 4 There are restrictions on coverage for some drugs

Section 4.1 Why do some drugs have restrictions?

For certain prescription drugs, special rules restrict how and when the plan covers them. A team of doctors

and pharmacists developed these rules to help our members use drugs in the most effective ways. These

special rules also help control overall drug costs, which keeps your drug coverage more affordable.

In general, our rules encourage you to get a drug that works for your medical condition and is safe and

effective. Whenever a safe, lower-cost drug will work just as well medically as a higher-cost drug, the plan’s

rules are designed to encourage you and your provider to use that lower-cost option. We also need to comply

with Medicare’s rules and regulations for drug coverage and cost-sharing.



If there is a restriction for your drug, it usually means that you or your doctor will have to take extra

steps in order for us to cover the drug. If you want us to waive the restriction for you, you will need to use

the coverage decision process and ask us to make an exception. We may or may not agree to waive the

restriction for you. (See Chapter 7, Section 5.2 for information about asking for exceptions.)

Please note that sometimes a drug may appear more than once in our Drug List. This is because different

restrictions or cost-sharing may apply based on factors such as the strength, amount or form of the drug

prescribed by your healthcare provider (for instance, 10mg versus 100mg; one per day versus two per day;

tablet versus liquid).

Section 4.2 What kinds of restrictions?

Our plan uses different types of restrictions to help our members use drugs in the most effective ways. The

following sections tell you more about the types of restrictions we use for certain drugs.

Getting plan approval in advance

For certain drugs, you or your doctor needs to get approval from the plan before we will agree to cover the

drug for you. This is called prior authorization. Sometimes the requirement for getting approval in advance

helps guide appropriate use of certain drugs. If you do not get this approval, your drug might not be covered

by the plan.

Trying a different drug first

This requirement encourages you to try less costly but just as effective drugs before the plan covers another

drug. For example, if Drug A and Drug B treat the same medical condition, the plan may require you to try

Drug A first. If Drug A does not work for you, the plan will then cover Drug B. This requirement to try a

different drug first is called step therapy.

Quantity limits

For certain drugs, we limit the amount of the drug that you can have. For example, the plan might limit how

many refills you can get or how much of a drug you can get each time you fill your prescription. For

example, if it is normally considered safe to take only one pill per day for a certain drug, we may limit

coverage for your prescription to no more than one pill per day.

Section 4.3 Do any of these restrictions apply to your drugs?

To find out if any of these restrictions apply to a drug you take or want to take, check the plan’s Drug List.

For the most up-to-date plan-specific information, call Customer Service (phone numbers are listed on the

back of your member ID card) or check our website at http://www.Express-Scripts.com.

If there is a restriction for a drug, it usually means that you or your doctor will have to take

extra steps in order for us to cover the drug. You should contact Customer Service to learn what

you or your doctor would need to do to get coverage for the drug. Phone numbers for Customer

Service are listed on the back of your member ID card. If you want us to waive the restriction for

you, you will need to use the coverage decision process and ask us to make an exception. We may or

may not agree to waive the restriction for you. (See Chapter 7, Section 5.2 for information about

asking for exceptions.)



SECTION 5 What if one of your drugs is not covered in the way you’d like it to be covered?

Section 5.1 There are things you can do if your drug is not covered in the way you’d like

it to be covered

We hope that your drug coverage will work well for you. But it’s possible there could be a prescription drug

you are currently taking, or one that you and your doctor think you should be taking, that is on our

formulary with restrictions. For example:

The drug is covered, but there are extra rules or restrictions on coverage for that drug. As explained in

Section 4, some of the drugs covered by the plan have extra rules to restrict their use. For example, you

might be required to try a different drug first, to see if it will work, before the drug you want to take will be

covered for you. Or there might be limits on what amount of the drug (number of pills, etc.) is covered

during a particular time period. In some cases, you may want us to waive the restriction for you.

The drug is covered, but it is in a cost-sharing tier that makes your cost-sharing more expensive than

you think it should be. The plan puts covered drugs into different cost-sharing tiers. How much you pay for

your prescription depends in part on which cost-sharing tier your drug is in.

Section 5.2 What can you do if your drug is restricted in some way?

If your drug is restricted, here are things you can do:

You may be able to get a temporary supply of the drug (only members in certain situations can get a

temporary supply). This will give you and your doctor time to change to another drug or to file a request

to have the drug covered.

You can change to another drug.

You can request an exception and ask the plan to cover the drug or remove restrictions from the drug.

You may be able to get a temporary supply

Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is

restricted in some way. Doing this gives you time to talk with your doctor about the change in coverage and

figure out what to do.

To be eligible for a temporary supply, you must meet the two requirements below:

1. The change to your drug coverage must be one of the following types of changes:

The drug you have been taking is no longer covered by the plan.

– or – the drug you have been taking is now restricted in some way (Section 4 in this chapter tells

about restrictions).

2. You must be in one of the situations described below:

For those members who are new or who were in the plan last year and aren’t in a long-term

care (LTC) facility:

We will cover a temporary supply of a drug that you took during the prior plan year during the first

90 days of your membership in the plan if you were new and during the first 90 days of the

calendar year if you were in the plan last year. This temporary supply will be for at least 30 days,

or less if your prescription is written for fewer days. In that case, you will be allowed multiple fills to

provide up to a total of at least a 30-day supply of the medication. The prescription must be filled at

a network pharmacy.



For those members who are new or who were in the plan last year and reside in an LTC

facility:

We will cover a temporary supply of your drug during the first 90 days of your membership in

the plan if you are new and during the first 90 days of the calendar year if you were in the plan

last year. The total supply will be for a maximum of a 98-day supply. If your prescription is written

for fewer days, we will allow multiple fills to provide up to a maximum of a 98-day supply of

medication. (Please note that the LTC pharmacy may provide the drug in smaller amounts at a time

to prevent waste.)

For those who have been a member of the plan for more than 90 days and reside in an LTC

facility and need a supply right away:

We will cover one 31-day supply, or less if your prescription is written for fewer days. This is in

addition to the above LTC transition supply.

Other times when we will cover at least a temporary 30-day transition supply (or less if you have a

prescription written for fewer days) include:

When you enter an LTC facility

When you leave an LTC facility

When you are discharged from a hospital

When you leave a skilled nursing facility

When you cancel hospice care

When you are discharged from a psychiatric hospital with a medication regimen that is

highly individualized

To ask for a temporary supply, call Customer Service (phone numbers are listed on the back of your member

ID card).

During the time when you are getting a temporary supply of a drug, you should talk with your doctor to

decide what to do when your temporary supply runs out. You can either switch to a different drug covered

by the plan or ask the plan to make an exception for you and cover your current drug. The sections below

tell you more about these options.

You can change to another drug

Start by talking with your doctor. Perhaps there is a different drug covered by the plan that might work just

as well for you. You can call Customer Service to ask for a list of covered drugs that treat the same medical

condition. This list can help your doctor find a covered drug that might work for you.

You can ask for an exception

You and your doctor can ask the plan to make an exception for you and cover the drug in the way you would

like it to be covered. If your doctor says that you have medical reasons that justify asking us for an

exception, your doctor can help you request an exception to the rule. For example, you can ask the plan to

cover a drug that is not currently covered. Or you can ask the plan to make an exception and cover the drug

without restrictions.

If you and your doctor want to ask for an exception, Chapter 7, Section 5.4 explains the procedures and

deadlines that have been set by Medicare to make sure your request is handled promptly and fairly.



SECTION 6 What if your coverage changes for one of your drugs?

Section 6.1 Your drug coverage can change during the year

Most of the changes in drug coverage happen at the beginning of each year (January 1). However, during the

year, the plan might make changes to its drug coverage. For example, the plan might:

Add or remove drugs from coverage. New drugs become available, including new generic drugs.

Perhaps the government has given approval to a new use for an existing drug. Sometimes, a drug

gets recalled and we decide not to cover it. Or we might remove a drug from coverage because it has

been found to be ineffective.

Move a drug to a higher or lower cost-sharing tier.

Add or remove a restriction on coverage for a drug (for more information about restrictions to

coverage, see Section 4 in this chapter).

In almost all cases, we must get approval from Medicare for changes we make to the plan’s drug coverage.

Section 6.2 What happens if coverage changes for a drug you are taking?

How will you find out if your drug’s coverage has been changed?

If there is a change to coverage for a drug you are taking, the plan will send you a notice to tell you.

Normally, we will let you know at least 60 days ahead of time.

Once in a while, a drug is suddenly recalled because it’s been found to be unsafe or for other reasons. If

this happens, the plan will immediately remove the drug from plan coverage. We will let you know of this

change right away. Your doctor will also know about this change and can work with you to find another

drug for your condition.

Do changes to your drug coverage affect you right away?

If any of the following types of changes affect a drug you are taking, the change will not affect you until

January 1 of the next year if you stay in the plan:

If we move your drug into a higher cost-sharing tier

If we put a new restriction on your use of the drug

If we stop covering a drug, but not because of a sudden recall or because a new generic drug

has replaced it

If any of these changes happens for a drug you are taking, then the change won’t affect your use or what you

pay as your share of the cost until January 1 of the next year. Until that date, you probably won’t see any

increase in your payments or any added restriction to your use of the drug.

In some cases, you will be affected by the coverage change before January 1:

If a brand-name drug you are taking is replaced by a new generic drug, the plan must give you

at least 60 days’ notice or give you a 60-day refill of your brand-name drug at a network pharmacy.

o During this 60-day period, you should be working with your doctor to switch to the generic or to

a different drug that we cover.

o Or you and your doctor can ask the plan to make an exception and continue to cover the brand-

name drug for you. For information on how to ask for an exception, see Chapter 7.



Again, if a drug is suddenly recalled because it’s been found to be unsafe or for other reasons, the

plan will immediately remove the drug from the Drug List. We will let you know of this change right

away.

o Your doctor will also know about this change and can work with you to find another drug for

your condition.

SECTION 7 What types of drugs are not covered by the plan?

Section 7.1 Types of drugs we do not cover

This section tells you what kinds of prescription drugs are “excluded.” This means Medicare does not pay

for these drugs.

If you get drugs that are excluded, you must pay for them yourself. We won’t pay for the drugs listed in this

section. The only exception: If the requested drug is found upon appeal to be a drug that is not excluded

under Part D and we should have paid for or covered it because of your specific situation. (For information

about appealing a decision we have made to not cover a drug, go to Chapter 7, Section 5.5.)

Here are three general rules about drugs that Medicare drug plans will not cover under Part D:

Our plan’s Part D drug coverage cannot cover a drug that would be covered under Medicare Part A

or Part B.

Our plan cannot cover a drug purchased outside the United States and its territories.

Our plan usually cannot cover off-label use. “Off-label use” is any use of the drug other than those

indicated on a drug’s label, as approved by the FDA.

o Generally, coverage for off-label use is allowed only when the use is supported by certain

reference books. These reference books are the American Hospital Formulary Service Drug

Information, the DRUGDEX Information System, and for cancer, the National Comprehensive

Cancer Network and Clinical Pharmacology, or their successors. If the use is not supported by

any of these reference books, then our plan cannot cover its off-label use.

Also, by law, the following categories of drugs are not covered by Medicare Part D plans. However, see

your plan materials to find out if your former employer or your retiree group provides additional coverage

of some of these drugs. Please call Customer Service for drug coverage specifics.

Drugs when used for anorexia, weight loss or weight gain

Drugs when used to promote fertility

Drugs when used for cosmetic purposes or to promote hair growth

Prescription drugs when used for the relief of cough or colds

Prescription vitamins and mineral products (except prenatal vitamins and fluoride preparations,

which are considered Part D drugs)

Drugs, such as CAVERJECT®, CIALIS

®, EDEX

®, LEVITRA

®, MUSE

® and VIAGRA

®, when used

for the treatment of sexual or erectile dysfunction

Over-the-counter (OTC) diabetic supplies

Federal Legend Part B medications – for example, oral chemotherapy agents

(e.g., TEMODAR®, XELODA

®)

Non-prescription drugs, also known as over-the-counter (OTC) drugs

Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring

services be purchased exclusively from the manufacturer as a condition of sale



In addition, if you are receiving Extra Help from Medicare to pay for your prescriptions, the Extra Help

program will not pay for the drugs not normally covered. Please refer to your formulary or call Customer

Service for more information. Phone numbers for Customer Service are listed on the back of your member

ID card.

If you receive Extra Help paying for your drugs or have drug coverage through Medicaid, your state

Medicaid program may cover some prescription drugs not normally covered in a Medicare drug plan. Please

contact your state Medicaid program to determine what drug coverage may be available to you. (You can

find phone numbers and contact information for Medicaid in the Appendix.)

If your former employer or your retiree group does provide coverage of drugs not typically covered under a

Medicare prescription drug plan, the amount you pay when you fill a prescription for these drugs does not

count toward qualifying you for the Catastrophic Coverage stage. (The Catastrophic Coverage stage is

described in Chapter 4, Section 7.)

SECTION 8 Show your member ID card when you fill a prescription

Section 8.1 Show your member ID card

To fill your prescription, show your member ID card at the network pharmacy you choose. When you show

your member ID card, the network pharmacy will automatically bill the plan for our share of your covered

prescription drug cost. You will need to pay the pharmacy your share of the cost when you pick up your

prescription.

Section 8.2 What if you don’t have your member ID card with you?

If you don’t have your member ID card with you when you fill your prescription, ask the pharmacy to call

Express Scripts to get the necessary information.

If the pharmacy is not able to get the necessary information, you may have to pay the full cost of the

prescription when you pick it up. (You can then ask us to reimburse you for our share. See Chapter 5,

Section 2.1 for information about how to ask the plan for reimbursement.)

SECTION 9 Part D drug coverage in special situations

Section 9.1 What if you’re in a hospital or a skilled nursing facility for a stay that is covered by

Original Medicare?

If you are admitted to a hospital for a stay covered by Original Medicare, Medicare Part A will generally

cover the cost of your prescription drugs during your stay. Once you leave the hospital, our plan will cover

your drugs as long as the drugs meet all of our rules for coverage. See the previous parts of this chapter that

tell about the rules for getting drug coverage.

If you are admitted to a skilled nursing facility for a stay covered by Original Medicare, Medicare Part A

will generally cover your prescription drugs during all or part of your stay. If you are still in the skilled

nursing facility and Part A is no longer covering your drugs, our plan will cover your drugs as long as the

drugs meet all of our rules for coverage. See the previous parts of this chapter that tell about the rules for

getting drug coverage.



Please Note: When you enter, live in or leave a skilled nursing facility, you are entitled to a Special

Enrollment Period. During this time period, you can switch plans or change your coverage. (Chapter 8 tells

when you can leave our plan and join a different Medicare plan.)

Section 9.2 What if you’re a resident in a long-term care (LTC) facility?

Usually, a long-term care (LTC) facility (such as a nursing home) has its own pharmacy, or a pharmacy that

supplies drugs for all of its residents. If you are a resident of an LTC facility, you may get your prescription

drugs through the facility’s pharmacy as long as it is part of our network.

Check your Pharmacy Directory to find out if your LTC facility’s pharmacy is part of our network. If it

isn’t, or if you need more information, please contact Customer Service. Phone numbers for Customer

Service are listed on the back of your member ID card.

What if you’re a resident in an LTC facility and become a new member of the plan?

If you need a drug that is restricted in some way, the plan will cover a temporary supply of your drug

during the first 90 days of your membership. The total supply will be for a maximum of a 98-day supply, or

less if your prescription is written for fewer days. (Please note that the LTC pharmacy may provide the drug

in smaller amounts at a time to prevent waste.) If needed, we will cover additional refills during your first

90 days in the plan.

If you have been a member of the plan for more than 90 days and need a drug that has restrictions on its

coverage, we will cover one 31-day supply, or less if your prescription is written for fewer days.

During the time when you are getting a temporary supply of a drug, you should talk with your doctor to

decide what to do when your temporary supply runs out. Perhaps there is a different drug covered by the

plan that might work just as well for you. Or you and your doctor can ask the plan to make an exception for

you and cover the drug in the way you would like it to be covered. If you and your doctor want to ask for an

exception, Chapter 7, Section 5.4 tells what to do.

Section 9.3 What if you are taking drugs covered by Original Medicare?

Your enrollment in Express Scripts Medicare doesn’t affect your coverage for drugs covered under

Medicare Part A or Part B. If you meet Medicare’s coverage requirements, your drug will still be covered

under Medicare Part A or Part B, even though you are enrolled in this plan. In addition, if your drug would

be covered by Medicare Part A or Part B, our plan can’t cover it, even if you choose not to enroll in Part A

or Part B.

Some drugs may be covered under Medicare Part B in some situations and through Express Scripts

Medicare in other situations. But drugs are never covered by both Part B and our plan at the same time. In

general, your pharmacist or provider will determine whether to bill Medicare Part B or Express Scripts

Medicare for the drug.

Section 9.4 What if you have a Medigap (Medicare Supplement Insurance) policy with prescription

drug coverage (other than through your former employer or retiree group)?

If you currently have a Medigap policy that includes coverage for prescription drugs, you must contact your

Medigap issuer and tell them you have enrolled in our plan. If you decide to keep your current Medigap



policy, your Medigap issuer will remove the prescription drug coverage portion of your Medigap policy and

lower your premium.

Each year your Medigap insurance company should send you a notice that tells if your prescription drug

coverage is creditable and the choices you have for drug coverage. (If the coverage from the Medigap policy

is creditable, it means that it is expected to pay, on average, at least as much as Medicare’s standard

prescription drug coverage.) The notice will also explain how much your premium would be lowered if you

remove the prescription drug coverage portion of your Medigap policy. If you didn’t get this notice, or if

you can’t find it, contact your Medigap insurance company and ask for another copy.

Keep these notices about creditable coverage, because you may need them later. If you enroll in a

different Medicare plan that includes Part D drug coverage, you may need these notices to show that you

have maintained creditable coverage. If you didn’t get a notice about creditable coverage from your

employer or retiree group plan, you can get a copy from the employer or retiree group’s benefits

administrator.

Section 9.5 What if you are in Medicare-certified Hospice?

Drugs are never covered by both hospice and our plan at the same time. If you are enrolled in Medicare

hospice and require an antinausea, laxative, pain medication, or antianxiety drug that is not covered by your

hospice because it is unrelated to your terminal illness and related conditions, our plan must receive

notification from either the prescriber or your hospice provider that the drug is unrelated before our plan can

cover the drug. To prevent delays in receiving any unrelated drugs that should be covered by our plan, you

can ask your hospice provider or prescriber to make sure we have the notification that the drug is unrelated

before you ask a pharmacy to fill your prescription.

In the event you either revoke your hospice election or are discharged from hospice, our plan should cover

all your drugs. To prevent any delays at a pharmacy when your Medicare hospice benefit ends, you should

bring documentation to the pharmacy to verify your revocation or discharge. See the previous parts of this

section that tell about the rules for getting drug coverage under Part D. Chapter 4 gives more information

about drug coverage and what you pay.

SECTION 10 Programs on drug safety and managing medications

Section 10.1 Programs to help members use drugs safely

We conduct drug use reviews for our members to help make sure that they are getting safe and appropriate

care. These reviews are especially important for members who have more than one doctor who prescribes

their drugs.

We do a review each time you fill a prescription. We also review our records on a regular basis. During

these reviews, we look for potential problems, such as:

Possible medication errors

Drugs that may not be necessary because you are taking another drug for the same medical condition

Drugs that may not be safe or appropriate because of your age or gender

Certain combinations of drugs that could harm you if taken at the same time

Prescriptions written for drugs that have ingredients you are allergic to

Possible errors in the amount (dosage) of a drug you are taking



If we see a possible problem in your use of medications, we will work with your doctor to correct

the problem.

Section 10.2 A program to help members manage their medications

We have a Medication Therapy Management (MTM) program that can help our members with complex

health needs. For example, some members have several medical conditions, take different drugs at the same

time and have high drug costs.

This program is voluntary and free to members. A team of pharmacists and doctors developed it for us. The

program can help make sure that our members get the most benefit from the drugs they take.

A pharmacist or other health professional will give you a comprehensive review of all your medications.

You can talk about how best to take your medications, your costs and any problems or questions you have

about your prescription and over-the-counter medications. You’ll get a written summary of this discussion.

The summary has a medication action plan that recommends what you can do to make the best use of your

medications, with space for you to take notes or write down any follow-up questions. You’ll also get a

personal medication list that will include all the medications you’re taking and why you take them.

It’s a good idea to have your medication review before your yearly “Wellness” visit, so you can talk to your

doctor about your action plan and medication list. Bring your action plan and medication list with you to

your visit or anytime you talk with your doctors, pharmacists, and other healthcare providers. Also, keep

your medication list with you (for example, with your member ID card) in case you go to the hospital or

emergency room.

If this program fits your needs, we will automatically enroll you in the program and send you information. If

you decide not to participate, please notify us and we will withdraw you from the program. If you have any

questions about this program, please contact Customer Service (phone numbers are listed on the back of

your member ID card).


Chapter 4: Paying for your Part D prescription drugs 33

Chapter 4. Paying for your Part D prescription drugs

? Did you know there are programs to help people pay for their drugs?

There are programs to help people with limited resources pay for their drugs. These

include Extra Help and State Pharmaceutical Assistance Programs (SPAPs). For more

information, see the Appendix.

Are you currently getting help to pay for your drugs?

If you are in a program that helps pay for your drugs, some information in this

Evidence of Coverage about the costs for Part D prescription drugs may not

apply to you. Please review the notice entitled “Important Information for Those Who

Receive Extra Help Paying for Their Prescription Drugs” (Low Income Subsidy (LIS)

Rider), which tells you about your drug coverage. If you don’t have this notice, please

call Customer Service and ask for the LIS Rider. Phone numbers for Customer Service

are listed on the back of your member ID card.


Section 1.1 Use this chapter together with other materials that explain your drug coverage

This chapter focuses on what you pay for your Part D prescription drugs. To keep things simple, we use

“drug” in this chapter to mean a Part D prescription drug. As explained in Chapter 3, not all drugs are

Part D drugs — some drugs are covered under Medicare Part A or Part B and other drugs are excluded by

law from Medicare coverage.

To understand the payment information we give you in this chapter, you need to know the basics of what

drugs are covered, where to fill your prescriptions and what rules to follow when you get your covered

drugs. Examples of some of the materials where you can find more information about your specific plan

include the Benefit Overview, the Quick Reference Guide, the 2017 Formulary (List of Covered Drugs) and

any notices you receive from us about changes to your coverage or conditions that affect your coverage.

Chapter 3 gives the details about your prescription drug coverage, including rules you need to follow when

you get your covered drugs. Chapter 3 also tells which types of prescription drugs are not covered by our

plan.

In most situations, you must use a network pharmacy to get your covered drugs (see Chapter 3 for the

details). The Pharmacy Directory has a list of the closest retail pharmacies in the plan’s network, as well as

other pharmacies in the network. It also explains which pharmacies offer up to a three-month supply.

Section 1.2 Types of out-of-pocket costs you may pay for covered drugs

To understand the payment information we give you in this chapter, you need to know about the types of

out-of-pocket costs you may pay for your covered services. The amount that you pay for a drug is called

“cost-sharing,” and there are three ways you may be asked to pay.

The “deductible” is the amount you must pay for drugs before our plan begins to pay its share.

“Copayment” means that you pay a fixed amount each time you fill a prescription.

“Coinsurance” means that you pay a percent of the total cost of the drug each time you fill

a prescription.



SECTION 2 What you pay for a drug depends on the plan selected by your former employer

or your retiree group and which drug payment stage you are in when you get

the drug

Section 2.1 What are the standard Part D drug payment stages?

As shown in the table below, there are typically four drug payment stages for Medicare Part D plans. The

plan selected by your former employer or retiree group will determine if your plan has a Deductible or

Coverage Gap stage and how these stages will apply (see your other plan materials for more details).

How much you pay for a drug depends on which of these stages you are in at the time you get a prescription

filled or refilled. Keep in mind you are always responsible for the plan’s monthly premium (if applicable),

regardless of the drug payment stage you are in.

NOTE: Check your Benefit Overview or Annual Notice of Changes to see if your former employer or your

retiree group has an annual prescription drug out-of-pocket maximum. If so, you may pay a reduced cost or

pay nothing once you reach that annual out-of-pocket maximum amount.

STAGE 1

Yearly Deductible stage

STAGE 2

Initial Coverage stage

STAGE 3

Coverage Gap stage

STAGE 4

Catastrophic Coverage

stage

If your plan has a

deductible, you begin in

this stage when you fill

your first prescription of

the plan year. During

this stage, you pay the

full cost of your drugs.

You stay in this stage

until you have paid the

deductible listed in your

Benefit Overview or

Annual Notice of

Changes.

(Details are in Section 4

of this chapter.)

During this stage, the

plan pays its share of

the cost of your drugs

and you pay your share

of the cost. Your share

is shown in your Benefit

Overview or Annual

Notice of Changes.

After you (or others on

your behalf) have met

your deductible (if your

plan has a deductible),

the plan pays its share

of the cost of your drugs

and you pay your share.


until your year-to-date

“total drug costs” (your payments plus any

Part D plan’s payments)

total $3,700.


of this chapter.)

Refer to your Benefit

Overview or Annual

Notice of Changes to

determine if your plan

has a Coverage Gap and

what you and the plan

will pay during this

stage.


until your year-to-date

out-of-pocket costs (your payments) reach a

total of $4,950. This

amount and rules for

counting costs toward

this amount have been

set by Medicare.


of this chapter.)

During this stage, the

plan will pay most of

the cost of your drugs

for the rest of the plan

year (through

December 31, 2017).


of this chapter.)



SECTION 3 We will send you a Part D Explanation of Benefits (Part D EOB) that explains

payments for your drugs and which payment stage you are in

Section 3.1 We send you a monthly summary called the Part D Explanation of Benefits (the Part D

EOB)

Our plan keeps track of the costs of your prescription drugs and the payments you have made when you get

your prescriptions filled or refilled at the pharmacy. This way, we can tell you when you have moved from

one drug payment stage to the next. In particular, there are two types of costs we keep track of:

We keep track of how much you have paid. This is called your out-of-pocket costs.

We keep track of your total drug costs. This is the amount you pay out-of-pocket and/or others

pay on your behalf, plus the amount paid by the plan.

We will send you a summary called the Part D Explanation of Benefits (Part D EOB) when you have had

one or more prescriptions filled through the plan during the previous month. It includes:

Information for that month. This report gives the payment details about the prescriptions you have

filled during the previous month. It shows your total drug costs, including what the plan paid and

what you and others on your behalf paid.

Totals for the year since January 1. This is called “year-to-date” information. It shows you the

total drug costs and total payments for your drugs for the year since the year began.

Section 3.2 Help us keep our information about your drug payments up to date

To keep track of your drug costs and the payments you make for drugs, we use records we get from

pharmacies. Here is how you can help us keep your information correct and up to date:

Show your member ID card when you get a prescription filled. To make sure we know about the

prescriptions you are filling and what you are paying, show your member ID card every time you get

a prescription filled.

Make sure we have the information we need. There are times you may pay for prescription drugs

when we will not automatically get the information we need to keep track of your out-of-pocket

costs. To help us keep track, you may give us copies of receipts for drugs that you have purchased.

(If you are billed for a covered drug, you can ask our plan to pay our share of the cost. For

instructions, go to Chapter 5, Section 2.) Here are some types of situations when you may want to

give us copies of your drug receipts to be sure we have a complete record of what you have spent for

your drugs:

o When you purchased a covered drug at a network pharmacy at a special price or used a

discount card that was not part of our plan’s benefit.

o When you made a copayment for drugs that are provided under a drug manufacturer patient

assistance program.

o Anytime you have purchased covered drugs at out-of-network pharmacies or other times you

have paid the full price for a covered drug under special circumstances.

Send us information about the payments others have made for you. Payments made by certain

other individuals and organizations also count toward your out-of-pocket costs and help qualify you

for the Catastrophic Coverage stage. For example, payments made by a State Pharmaceutical

Assistance Program, an AIDS drug assistance program (ADAP), the Indian Health Service and most

charities count toward your out-of-pocket costs. You should keep a record of these payments and

send them to us so we can track your costs.



Check the written report we send you. When you receive a Part D EOB, please look it over to be

sure the information is complete and correct. If you think something is missing from the report, or

you have any questions, please call us at Customer Service (phone numbers are listed on the back of

your member ID card). Be sure to keep these reports. They are an important record of your drug

expenses.

SECTION 4 If the Deductible stage applies to your former employer or your retiree group plan,

you pay the full cost of your drugs during this stage

Section 4.1 If your plan has a Deductible stage, you stay in this stage until you have paid the

amount listed in your Benefit Overview or Annual Notice of Changes

If your plan does not have a deductible, please skip to Section 5.

The Deductible stage is the first payment stage for your drug coverage. It begins when you fill your first

applicable prescription of the plan year. You will pay a yearly deductible in the amount listed in your Benefit

Overview or Annual Notice of Changes. When you are in this stage, you must pay the full cost of your

drugs that apply to your deductible until you reach the plan’s deductible amount. Please refer to your

Benefit Overview or Annual Notice of Changes to determine the amount of your deductible and to which

drugs your deductible applies.

Your full cost is usually lower than the normal full price of the drug, since our plan has negotiated

lower costs for most drugs.

The deductible is the amount you must pay for your Part D prescription drugs before the plan begins

to pay its share.

Once you have paid the applicable deductible, you leave the Deductible stage and move on to the next drug

payment stage, which is the Initial Coverage stage.

SECTION 5 During the Initial Coverage stage, the plan pays its share of your drug costs and

you pay your share

Section 5.1 What you pay for a drug depends on the drug and where you fill your prescription

During the Initial Coverage stage, the plan pays its share of the cost of your covered prescription drugs and

you pay your share (your copayment or coinsurance amount). Your share of the cost may vary, depending on

the drug and where you fill your prescription.

Your pharmacy choices

How much you pay for a drug depends on whether you get the drug from:

A retail pharmacy that is in our plan’s network

A retail pharmacy in our plan’s network that offers preferred cost-sharing, if your plan offers

preferred and standard cost-sharing

A pharmacy that is not in the plan’s network

The plan’s home delivery pharmacy

For more information about these pharmacy choices and filling your prescriptions, see Chapter 3 and the

plan’s Pharmacy Directory.



Generally, we will cover your prescriptions only if they are filled at one of our network pharmacies. If your

plan has pharmacies that offer preferred cost-sharing, you may go to either network pharmacies that offer

preferred cost-sharing or other network pharmacies that offer standard cost-sharing to receive your covered

prescription drugs. Your costs may be less at pharmacies that offer preferred cost-sharing. If your specific

plan has network pharmacies that offer preferred cost-sharing, the Pharmacy Directory will also tell you

which of the pharmacies in our network offer preferred cost-sharing.

Section 5.2 Your costs for covered Part D drugs

During the Initial Coverage stage, your share of the cost of a covered drug will be either a copayment or

coinsurance.

Copayment means that you pay a fixed amount each time you fill a prescription.

Coinsurance means that you pay a percent of the total cost of the drug each time you

fill a prescription.

As shown in other plan documents you have received, the amount of the copayment or coinsurance also

depends on which tier your drug is in.

If your covered drug costs less than the copayment amount listed in your other plan materials, you

will pay that lower price for the drug. You pay either the full price of the drug or the copayment

amount, whichever is lower.

We cover prescriptions filled at out-of-network pharmacies only in limited situations. Please see

Chapter 3, Section 2.5 for information about when we will cover a prescription filled at an

out-of-network pharmacy.

Section 5.3 If your doctor provides less than a full month’s supply, you may not have to pay the cost

of the entire month’s supply

Typically, the amount you pay for a prescription drug covers a full month’s supply of a covered drug.

However, your doctor can prescribe less than a month’s supply of drugs. There may be times when you

want to ask your doctor about prescribing less than a month’s supply of a drug (for example, when you are

trying a medication for the first time that is known to have serious side effects). If your doctor prescribes

less than a full month’s supply, you will not have to pay for the full month’s supply for certain drugs.

The amount you pay when you get less than a full month’s supply will depend on whether you are

responsible for paying coinsurance (a percentage of the total cost) or a copayment (a flat dollar amount).

If you are responsible for coinsurance, you pay a percentage of the total cost of the drug. You pay

the same percentage regardless of whether the prescription is for a full month’s supply or for fewer

days. However, because the entire drug cost will be lower if you get less than a full month’s supply,

the amount you pay will be less.

If you are responsible for a copayment for the drug, your copayment will be based on the number

of days of the drug that you receive. We will calculate the amount you pay per day for your drug (the

“daily cost-sharing rate”) and multiply it by the number of days of the drug you receive.

o Here’s an example: Let’s say the copayment for your drug for a full month’s supply (a 31-day

supply) is $31. This means that the amount you pay per day for your drug is $1. If you receive a

7 days’ supply of the drug, your payment will be $1 per day multiplied by 7 days, for a total

payment of $7.

Daily cost-sharing allows you to make sure a drug works for you before you have to pay for an entire

month’s supply. You can also ask your doctor to prescribe, and your pharmacist to dispense, less than a full



month’s supply of a drug or drugs, if this will help you better plan refill dates for different prescriptions so

you can take fewer trips to the pharmacy. The amount you pay will depend on the days’ supply you receive.

Section 5.4 You stay in the Initial Coverage stage until your total drug costs for the year

reach $3,700

You stay in the Initial Coverage stage until the total amount for the prescription drugs you have filled and

refilled reaches the $3,700 limit for the Initial Coverage stage.

Your total drug cost is based on adding together what you have paid and what any Part D plan has paid:

What you have paid for all the covered drugs you have gotten since you started with your first

drug purchase of the plan year. (See Section 6.2 for more information about how Medicare

calculates your out-of-pocket costs.) This includes:

o The deductible you paid when you were in the Deductible stage (if applicable)

o The total you paid as your share of the cost for your drugs during the Initial Coverage stage

What the plan has paid as its share of the cost for your drugs during the Initial Coverage stage. (If

you were enrolled in a different Part D plan at any time during 2017, the amount that plan paid

during the Initial Coverage stage also counts toward your total drug costs.)

The Part D EOB that we send to you will help you keep track of how much you and the plan, as well as any

third parties, have spent on your behalf for your drugs during the year. Many people do not reach the $3,700

limit in a year. If you do reach this amount, we’ll let you know. You will leave the Initial Coverage stage and

move on to the Coverage Gap stage.

Please refer to your other plan materials for your plan-specific coverage in the Initial Coverage stage.

If your plan does not have a Coverage Gap stage, you will remain in the Initial Coverage stage until your

total out-of-pocket costs reach $4,950. Once you reach this amount, you will move into the Catastrophic

Coverage stage.

SECTION 6 Refer to your other plan materials to see what you pay and what the plan pays

during the Coverage Gap stage

Section 6.1 You stay in the Coverage Gap stage until your out-of-pocket costs reach $4,950

When you are in the Coverage Gap stage, you pay what is shown in your other plan materials for this

stage until your yearly out-of-pocket payments reach a maximum amount that Medicare has set. In 2017,

that amount is $4,950.



Please refer to your other plan materials to determine if your plan has a Coverage Gap stage. If your

plan does have a Coverage Gap stage, your other plan materials will indicate any additional coverage

provided while in this stage.

Medicare Coverage Gap Discount Program

The Medicare Coverage Gap Discount Program provides manufacturer discounts on brand-name drugs to

Part D enrollees who either have reached the Coverage Gap stage or have a total drug spend of $3,700 and

are not receiving Extra Help. For brand-name drugs, manufacturers provide a 50% discount on the

negotiated price (excluding the dispensing fee, if any). The plan pays an additional 10% and you pay the

remaining 40% for your brand-name drugs. You pay the dispensing fee on the portion of the cost paid by the

plan (10% in 2017).

If you reach the Coverage Gap, we will automatically apply the discount when your pharmacy bills you for

your prescription, and your Part D EOB will show any discount provided. Both the amount you pay and the

amount discounted by the manufacturer count toward your out-of-pocket costs as if you had paid them

and move you through the Coverage Gap. The amount paid by the plan (10%) does not count toward your

out-of-pocket costs.

You also receive some coverage for generic drugs. If you reach the Coverage Gap, the plan pays 49% of the

price for generic drugs and you pay the remaining 51% of the price. The coverage for generic drugs works

differently than the 50% discount for brand-name drugs. For generic drugs, the amount paid by the plan

(49%) does not count toward your out-of-pocket costs. Only the amount you pay counts and moves you

through the Coverage Gap. Also, the dispensing fee is included as part of the cost of the drug.

If you have any questions about the availability of discounts for the drugs you are taking or about the

Medicare Coverage Gap Discount Program in general, please contact Customer Service (phone numbers are

listed on the back of your member ID card).

See your other plan materials for the specifics of your coverage during the Coverage Gap stage. Your

former employer or retiree group may provide continued coverage during the Coverage Gap stage for some

or all of your drugs, or your plan may not have a Coverage Gap stage at all.



Section 6.2 How Medicare calculates your out-of-pocket costs for prescription drugs

Here are Medicare’s rules that we must follow when we keep track of your out-of-pocket costs for your

drugs.

These payments are included in your

out-of-pocket costs

When you add up your out-of-pocket costs, you can include the payments listed below (as long

as they are for Part D covered drugs and you followed the rules for drug coverage that are

explained in Chapter 3):

The amount you pay for drugs when you are in any of the following drug payment stages:

o The Deductible stage, if applicable

o The Initial Coverage stage

o The Coverage Gap stage, if applicable

Any payments you made during this calendar year as a member of a different Medicare

prescription drug plan before you joined our plan.

It matters who pays:

If you make these payments yourself, they are included in your out-of-pocket costs.

These payments are also included if they are made on your behalf by certain other

individuals or organizations. This includes payments for your drugs made by a friend or

relative, by most charities, by AIDS drug assistance programs, by a State Pharmaceutical

Assistance Program that is qualified by Medicare or by the Indian Health Service.

Payments made by Medicare’s “Extra Help” Program are also included.

Some of the payments made by the Medicare Coverage Gap Discount Program are included.

The amount the manufacturer pays for your brand-name drugs is included. But the amount the

plan pays for your generic drugs is not included.

Moving on to the Catastrophic Coverage stage:

When you (or those paying on your behalf) have spent a total of $4,950 in out-of-pocket costs

within the calendar year, you will move on to the Catastrophic Coverage stage.



These payments are not included in

your out-of-pocket costs

When you add up your out-of-pocket costs, you are not allowed to include any of these types of

payments for prescription drugs:

The amount you or your former employer or your retiree group pays for your monthly premium

Drugs you buy outside the United States and its territories

Drugs that are not covered by our plan

Drugs you get at an out-of-network pharmacy that do not meet the plan’s requirements for

out-of-network coverage

Non-Part D drugs, including prescription drugs covered by Part A or Part B and other drugs

excluded from coverage by Medicare

Payments made by the plan for your brand or generic drugs while in the Coverage Gap stage

Payments for your drugs that are made by group health plans, including employer health plans

Payments for your drugs that are made by certain insurance plans and government-funded

health programs, such as TRICARE and the Veterans Administration

Payments for your drugs made by a third party with a legal obligation to pay for prescription

costs (for example, workers’ compensation)

Reminder: If any other organization, such as the ones listed above, pays part or all of your

out-of-pocket costs for drugs, you are required to tell our plan. Call Customer Service to let us know

(phone numbers are listed on the back of your member ID card).

How can you keep track of your out-of-pocket total?

We will help you. The Part D Explanation of Benefits (Part D EOB) summary we send to you

includes the current amount of your out-of-pocket costs (Section 3 in this chapter tells about this

report). When you reach a total of $4,950 in out-of-pocket costs for the year, this report will tell

you that you have moved on to the Catastrophic Coverage stage.

Make sure we have the information we need. Section 3.2 in this chapter tells what you can do to

help make sure that our records of what you have spent are complete and up to date.

SECTION 7 During the Catastrophic Coverage stage, the plan pays most of the cost for

your drugs

Section 7.1 Once you are in the Catastrophic Coverage stage, you will stay in this stage for the rest

of the year

You qualify for the Catastrophic Coverage stage when your out-of-pocket costs have reached the $4,950

limit for the calendar year. Once you are in the Catastrophic Coverage stage, you will stay in this payment

stage until the end of the calendar year.

During this stage, the plan will pay most of the cost for your drugs.



Your share of the cost for a covered drug will be either coinsurance or a copayment, whichever is

the larger amount:

o –either – coinsurance of 5% of the cost of the drug

o –or – a $3.30 copayment for covered generic drugs (including brand drugs treated

as generics)

and an $8.25 copayment for all other drugs.

Our plan pays the rest of the cost.

The amounts above are the standard Medicare Part D cost-sharing amounts. Please refer to your

Benefit Overview or Annual Notice of Changes to determine if your plan-specific coverage varies.

SECTION 8 What you pay for vaccinations covered by Part D depends on how and where

you get them

Section 8.1 Our plan may have separate coverage for the Part D vaccine medication itself and for

the cost of giving you the vaccination shot

Our plan provides coverage of a number of Part D vaccines. There are two parts to our coverage of

vaccinations:

The first part of coverage is the cost of the vaccine medication itself. The vaccine is a

prescription medication.

The second part of coverage is for the cost of giving you the vaccine. (This is sometimes called the

“administration” of the vaccine.)

What do you pay for a Part D vaccination?

What you pay for a Part D vaccination depends on three things:

1. The type of vaccine (what you are being vaccinated for)

o Some vaccines are considered Part D drugs. You can find these vaccines listed in the plan’s

2017 Formulary (List of Covered Drugs).

o Other vaccines are considered medical benefits. They are covered under Original Medicare.

2. Where you get the vaccine medication

3. Who gives you the vaccination shot

What you pay can also vary depending on the circumstances. For example:

Sometimes when you get your vaccine, you will have to pay the entire cost for both the vaccine

medication and for getting the vaccine. You can ask our plan to pay you back for our share of the

cost.

Other times, when you get the vaccine medication or the vaccine, you will pay only your share of the

cost.

To show how this works, here are three common ways you might get a Part D vaccine. Remember, you are

responsible for all of the costs associated with vaccines (including their administration) during the

Deductible and Coverage Gap stages of your benefit (if these stages are applicable). Your actual costs may

vary in each stage, depending on your plan design.



Situation 1: You buy the Part D vaccine at the pharmacy and you get your vaccine at a network

pharmacy. (Whether you have this choice depends on where you live. Some states do not

allow pharmacies to administer a vaccination.)

You will have to pay the pharmacy the amount of your copayment or coinsurance

for the vaccine and the cost of giving you the vaccine.

Our plan will pay its share of the cost.

Situation 2: You get the Part D vaccination at your doctor’s office.

When you get the vaccination, you will pay for the entire cost of the vaccine and

its administration.

You can then ask our plan to pay our share of the cost by using the procedures that

are described in Chapter 5.

You will be reimbursed the amount you paid, less your normal coinsurance or

copayment for the vaccine (including administration). Depending on how your

specific plan is set up, this reimbursement may also be less any difference

between the amount the doctor charges and what we normally pay. (If you get

Extra Help, we will reimburse you for this difference.)

Situation 3: You buy the Part D vaccine at your pharmacy and then take it to your doctor’s office,

where they give you the vaccine.

You will have to pay the pharmacy the amount of your coinsurance or

copayment for the vaccine itself.

When your doctor gives you the vaccine, you will pay the entire cost for this

service. You can then ask our plan to pay our share of the cost by using the

procedures described in Chapter 5.

You will be reimbursed the amount charged by the doctor for administering

the vaccine.

Section 8.2 You may want to call us before you get a vaccination

The rules for coverage of vaccinations are complicated. We’re here to help. We recommend that you call us

at Customer Service before getting vaccinated (phone numbers are listed on the back of your member ID

card).

We can tell you about how your vaccination is covered by our plan and explain your share

of the cost.

We can tell you how to keep your own cost down by using providers and pharmacies

in our network.

If you are not able to use a network provider and pharmacy, we can tell you what you need to do to

get payment from us for our share of the cost.

SECTION 9 Do you have to pay the Part D late enrollment penalty (LEP)?

Section 9.1 What is the Part D LEP?

Note: If you receive Extra Help from Medicare to pay for your prescription drugs, the LEP rules do not

apply to you. You will not pay an LEP.

The LEP is an amount that is added to your Part D premium. You may owe an LEP if at any time after your

initial enrollment period is over, there is a period of 63 days or more in a row when you did not have Part D



or other creditable prescription drug coverage. (“Creditable prescription drug coverage” is coverage that

meets Medicare’s minimum standards since it is expected to pay, on average, at least as much as Medicare’s

standard prescription drug coverage.) The amount of the penalty depends on how long you waited to enroll

in a creditable prescription drug coverage plan any time after the end of your initial enrollment period or

how many full calendar months you went without creditable prescription drug coverage.

The penalty may be added to your monthly premium. When you first enroll in Express Scripts Medicare, we

let you know the amount of the penalty. If you are responsible for an LEP, it is considered to be part of your

plan premium for as long as you have Part D coverage. If you do not pay your LEP, you could be

disenrolled for failure to pay your plan premium.

Section 9.2 How much is the Part D LEP?

Medicare determines the amount of the penalty. Here is how it works:

First count the number of full months that you delayed enrolling in a Medicare prescription drug

plan after you were eligible to enroll. Or count the number of full months in which you did not have

creditable prescription drug coverage, if the break in coverage was 63 days or more. The penalty is

1% for every month that you didn’t have creditable coverage. For our example, if you go 14 months

without coverage, the penalty will be 14%.

Then Medicare determines the amount of the average monthly premium for Medicare prescription

drug plans in the nation from the previous year. For 2017, this average premium amount is $35.63.

This amount may change for 2018.

To calculate your monthly penalty, you multiply the penalty percentage and the average monthly

premium and then round it to the nearest 10 cents. In the example here, it would be 14% times

$35.63, which equals $4.99. This rounds to $5.00. This amount would be added to the monthly

premium amount for someone with an LEP.

There are three important things to note about this monthly late enrollment penalty:

First, the penalty may change each year, because the average monthly premium can change each

year. If the national average premium (as determined by Medicare) increases, your penalty will

increase.

Second, you will continue to pay a penalty every month for as long as you are enrolled in a plan

that has Medicare Part D drug benefits.

Third, if you are under 65 and currently receiving Medicare benefits, the LEP will reset when you

turn 65. After age 65, your LEP will be based only on the months that you don’t have coverage after

your Initial Enrollment Period for aging into Medicare.

Section 9.3 In some situations, you can enroll late and not have to pay the penalty

Even if you have delayed enrolling in a plan offering Medicare Part D coverage when you were first

eligible, there are times when you may not have to pay the LEP.

You will not have to pay a penalty for late enrollment if you are in any of these situations:

If you already have prescription drug coverage that is expected to pay, on average, at least as much

as Medicare’s standard prescription drug coverage. Medicare calls this creditable coverage. Please

note:

o Creditable coverage could include drug coverage from a former employer or retiree group,

TRICARE or the Department of Veterans Affairs. Your insurer or your human resources

department will tell you each year if your drug coverage is creditable coverage. This



information may be sent to you in a letter or included in a newsletter from the plan. Keep this

information, because you may need it if you join a Medicare drug plan later.

Please note: If you receive a “certificate of creditable coverage” when your health

coverage ends, it may not mean your prescription drug coverage was creditable. The

notice must state that you had “creditable” prescription drug coverage that expected

to pay as much as Medicare’s standard prescription drug plan pays.

o The following are not creditable prescription drug coverage: prescription drug discount cards,

free clinics and drug discount websites.

o For additional information about creditable coverage, please look in your Medicare & You

2017 handbook or call Medicare at 1.800.MEDICARE (1.800.633.4227). TTY users call

1.877.486.2048. You can call these numbers for free, 24 hours a day, 7 days a week.

If you were without creditable coverage, but you were without it for less than 63 days in a row.

If you are receiving Extra Help from Medicare.

Section 9.4 What can you do if you disagree about your LEP?

If you disagree about your LEP, you or your representative can ask for a review of the decision about your

LEP. Generally, you must request this review within 60 days from the date on the letter you receive stating

you have to pay an LEP. Call Customer Service at the numbers listed on the back of your member ID card to

find out more about how to do this.

Important: Do not stop paying your LEP while you’re waiting for a review of the decision about your LEP.

If you do, you could be disenrolled for failure to pay your plan premiums.

SECTION 10 Do you have to pay an extra Part D amount because of your income?

Section 10.1 Who pays an extra Part D amount because of income?

Most people will pay their plan’s standard monthly Part D premium. However, some people pay an extra

amount because of their yearly income, which is called the Part D Income-Related Monthly Adjustment

Amount (Part D-IRMAA). If your income is greater than $85,000 for an individual (or married individuals

filing separately) or greater than $170,000 for married couples, you must pay an extra amount directly to the

government for your Medicare Part D coverage.

If you have to pay an extra amount, the Social Security Administration, not your Medicare plan, will send

you a letter telling you what that extra amount will be and how to pay it. The extra amount will be withheld

from your Social Security or Office of Personnel Management benefit check, no matter how you usually pay

your plan premium, unless your monthly benefit isn’t enough to cover the extra amount owed. If your

benefit check isn’t enough to cover the extra amount, you will get a bill from Medicare. You must pay the

extra amount to the government. It cannot be paid with your monthly plan premium.

Section 10.2 How much is the extra Part D amount?

If your modified adjusted gross income (MAGI) as reported on your Internal Revenue Service (IRS) tax

return is above a certain amount, you will pay an extra amount in addition to your monthly plan premium.

The table on the next page shows the extra amount based on your income.



If you filed an

individual tax return

and your income in

2015 was:

If you were married

but filed a separate

tax return and your

income in 2015 was:

If you filed a joint tax

return and your income

in 2015 was:

This is the monthly

cost of your extra

Part D amount

(to be paid in

addition to your

plan premium)

Equal to or less than

$85,000


$85,000


$170,000

$0

Greater than $85,000

and less than or equal to

$107,000

Greater than $170,000 and

less than or equal to

$214,000

$13.30



$160,000



$320,000

$34.20



$214,000


and less than or equal

to $129,000



$428,000

$55.20

Greater than $214,000 Greater than $129,000 Greater than $428,000 $76.20

Section 10.3 What can you do if you disagree about paying an extra Part D amount?

If you disagree about paying an extra amount because of your income, you can ask the Social Security

Administration to review the decision. To find out more about how to do this, contact the Social Security

Administration at 1.800.772.1213. Automated services are available 24 hours a day, 7 days a week. You

can speak with a representative between 7 a.m. and 7 p.m., Eastern Time, Monday through Friday. TTY

users should call 1.800.325.0778.

Section 10.4 What happens if you do not pay the extra Part D amount?

The extra amount is paid directly to the government (not your Medicare plan) for your Medicare Part D

coverage. If you are required to pay the extra amount and you do not pay it, you will be disenrolled

from the plan and lose prescription drug coverage.

SECTION 11 Information about programs to help people pay for their prescription drugs

Medicare’s Extra Help Program

Medicare provides Extra Help to pay prescription drug costs for people who have limited income and

resources. Resources include your savings and stocks, but not your home or car. If you qualify, you get

help paying for any Medicare drug plan’s monthly premium, yearly deductible and prescription

copayments or coinsurance. This Extra Help also counts toward your out-of-pocket costs.



People with limited income and resources may qualify for Extra Help. Some people automatically qualify

for Extra Help and don’t need to apply. Medicare mails a letter to people who automatically qualify for

Extra Help.

There are programs in Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands and

American Samoa to help people with limited income and resources pay their Medicare costs. Programs vary

in these areas. Call your local Medical Assistance (Medicaid) office to find out more about their rules (the

phone number is in the Appendix). Or call 1.800.MEDICARE (1.800.633.4227) 24 hours a day, 7 days a

week and say “Medicaid” for more information. TTY users should call 1.877.486.2048. You can also visit

http://www.medicare.gov for more information.

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you

qualify for getting Extra Help, call:

1.800.MEDICARE (1.800.633.4227). TTY users should call 1.877.486.2048, 24 hours a day,

7 days a week;

The Social Security Office at 1.800.772.1213, between 7:00 a.m. and 7:00 p.m., Eastern Time,

Monday through Friday. TTY users should call 1.800.325.0778 (applications); or

Your State Medicaid Office (applications). (See the Appendix for contact information.)

If you believe you have qualified for Extra Help and you believe that you are paying an incorrect

cost-sharing amount when you get your prescription at a pharmacy, our plan has established a process that

allows you either to request assistance in obtaining evidence of your proper copayment level, or, if you

already have the evidence, to provide this evidence to us.

We may be able to accept one of the following forms of Best Available Evidence (BAE) to establish that you

qualify for Extra Help, when the evidence is provided by you or your pharmacist, advocate, representative,

family member or other individual acting on your behalf:

1. A copy of the beneficiary’s Medicaid card that includes the beneficiary’s name and an eligibility date

during any month after June of the previous calendar year;

2. A copy of a state document that confirms active Medicaid status during any month after June of the

previous calendar year;

3. A printout from the state electronic enrollment file showing Medicaid status during any month after

June of the previous calendar year;

4. A screen print from the state’s Medicaid systems showing Medicaid status during any month after

June of the previous calendar year;

5. Other documentation provided by the state showing Medicaid status during any month after June of

the previous calendar year;

6. A letter from the Social Security Administration (SSA) showing that the individual receives

Supplemental Security Income (SSI); or

7. An Application Filed by Deemed Eligible confirming that the beneficiary is “…automatically

eligible for extra help…” (SSA publication HI 03094.605)

The following proofs of institutional status are acceptable from the beneficiary or the beneficiary’s

pharmacist, advocate, representative, family member or other individual acting on behalf of the beneficiary

to establish that a beneficiary is institutionalized, beginning on a date specified by the Secretary:

1. A remittance from the facility showing Medicaid payment for a full calendar month for that

individual during any month after June of the previous calendar year;



2. A copy of a state document that confirms Medicaid payment on behalf of the individual to the

facility for a full calendar month after June of the previous calendar year; or

3. A screen print from the state’s Medicaid systems showing that individual’s institutional status based

on at least a full calendar-month stay for Medicaid payment purposes during any month after June of

the previous calendar year.

The following proofs of status are acceptable from the beneficiary or the beneficiary’s pharmacist,

advocate, representative, family member or other individual acting on behalf of the beneficiary to establish

that an individual is receiving home and community-based services (HCBS) and qualifies for zero

cost-sharing effective as of a date specified by the Secretary:

1. A State-issued Notice of Action, Notice of Determination or Notice of Enrollment that includes the

beneficiary’s name and HCBS eligibility date during a month after June of the previous calendar

year;

2. A State-approved HCBS Service Plan that includes the beneficiary’s name and effective date

beginning during a month after June of the previous calendar year;

3. A State-issued prior authorization approval letter for HCBS that includes the beneficiary’s name and

effective date beginning during a month after June of the previous calendar year;

4. Other documentation provided by the State showing HCBS eligibility status during a month after

June of the previous calendar year; or

5. A State-issued document, such as a remittance advice, confirming payment for HCBS, including the

beneficiary’s name and the dates of HCBS.

You or your representative may fax or mail Best Available Evidence to the following fax number or address:

Fax: 1.855.297.7271

Address: Express Scripts Medicare (PDP)

P.O. Box 4558

Scranton, PA 18505

When we receive the evidence showing your copayment level, we will update our system so that you can

pay the correct copayment when you get your next prescription at the pharmacy. If you overpay your

copayment, we will reimburse you. Either we will forward a check to you in the amount of your

overpayment, or we will offset future copayments. If the pharmacy hasn’t collected a copayment from you

and is carrying your copayment as a debt owed by you, we may make the payment directly to the pharmacy.

If a state paid on your behalf, we may make payment directly to the state. Please contact Customer Service

if you have questions.

What if you have coverage from a State Pharmaceutical Assistance Program (SPAP)?

If you are enrolled in a State Pharmaceutical Assistance Program (SPAP), or any other program that

provides coverage for Part D drugs (other than Extra Help), you still get the 50% discount on covered

brand-name drugs. The 50% discount and the 10% paid by the plan are both applied to the price of the drug

before any SPAP or other coverage.

What if you have coverage from an AIDS Drug Assistance Program (ADAP)?

What is the AIDS Drug Assistance Program (ADAP)?

The AIDS Drug Assistance Program (ADAP) helps ensure that ADAP-eligible individuals living with

HIV/AIDS have access to life-saving HIV medications. Medicare Part D prescription drugs that are also



covered by ADAP qualify for prescription drug cost-sharing assistance in those states that have this

program. Note: To be eligible for the ADAP operating in your state, individuals must meet certain criteria,

including proof of state residence and HIV status, low income as defined by the state, and

uninsured/underinsured status.

If you are currently enrolled in an ADAP, it may continue to provide you with Medicare Part D prescription

cost-sharing assistance for drugs on the ADAP formulary. In order to be sure you continue receiving this

assistance, please notify your local ADAP enrollment worker of any changes in your Medicare Part D plan

name or policy number. For information on eligibility criteria, covered drugs, or how to enroll in the

program, please refer to the contact information located in the Appendix.

What if you get Extra Help from Medicare to help pay your prescription drug costs?

Can you get the discounts?

No. If you get Extra Help, you already get coverage for your prescription drug costs during the

Coverage Gap.

What if you don’t get a discount and you think you should have?

If you think that you have reached the Coverage Gap and did not get a discount when you paid for your

brand-name drug, you should review your next Part D Explanation of Benefits (Part D EOB) notice. If the

discount doesn’t appear on your Part D EOB, you should contact us to make sure that your prescription

records are correct and up to date. If we don’t agree that you are owed a discount, you can appeal. You can

get help filing an appeal from your State Health Insurance Assistance Program (SHIP) (telephone numbers

are in the Appendix) or by calling 1.800.MEDICARE (1.800.633.4227), 24 hours a day,

7 days a week. TTY users should call 1.877.486.2048.

State Pharmaceutical Assistance Programs (SPAPs)

Many states have State Pharmaceutical Assistance Programs (SPAPs) that help some people pay for

prescription drugs based on financial need, age, medical condition or disabilities. Each state has different

rules for providing drug coverage to its members. These programs provide limited-income and medically

needy seniors and individuals with disabilities financial help for prescription drugs. Contact information for

SPAPs is located in the Appendix.


Chapter 5: Asking us to pay our share of the costs for covered drugs 50

Chapter 5. Asking us to pay our share of the costs for covered drugs

SECTION 1 Situations in which you should ask us to pay our share of the cost of your

covered drugs

Section 1.1 If you pay our plan’s share of the cost of your covered drugs,

you can ask us for payment

Sometimes when you get a prescription drug, you may need to pay the full cost right away. Other times, you

may find that you have paid more than you expected under the coverage rules of the plan. In either case, you

can ask our plan to pay you back (paying you back is often called “reimbursing” you).

Here are examples of situations in which you may need to ask our plan to pay you back. All of these

examples are types of coverage decisions (for more information about coverage decisions, go to Chapter 7).

1. When you use an out-of-network pharmacy to get a prescription filled

If you go to an out-of-network pharmacy and try to use your member ID card to fill a prescription, the

pharmacy may not be able to submit the claim directly to us. When that happens, you will have to pay the

full cost of your prescription. (We cover prescriptions filled at out-of-network pharmacies only in a few

special situations. Please go to Chapter 3, Section 2.5 to learn more.)

Save your pharmacy prescription receipt and send a copy to us when you ask us to pay you back

for our share of the cost.

2. When you pay the full cost for a prescription because you don’t have your member ID card

with you

If you do not have your plan membership card with you, you can ask the pharmacy to call the plan or

look up your enrollment information. However, if the pharmacy cannot get the enrollment information

they need right away, you may need to pay the full cost of the prescription yourself.

Save your pharmacy prescription receipt and send a copy to us when you ask us to pay you back

for our share of the cost.

3. When you pay the full cost for a prescription in other situations

You may pay the full cost of the prescription because you find that the drug is not covered for

some reason.

For example, the drug may have a requirement or restriction that you didn’t know about or don’t

think should apply to you. If you decide to get the drug immediately, you may need to pay the full

cost for it. Save your pharmacy prescription receipt and send a copy to us when you ask us to pay

you back for our share of the cost.

If you are requesting payment for coverage of a Part D vaccine, such as a vaccine drug or

administration of a vaccine drug, please save your invoice (bill) from your doctor and send a copy

to us when you ask us to pay you back for our share of the cost.

In some situations, we may need to get more information from your doctor in order to pay you

back for our share of the cost.

4. If you are retroactively enrolled in our plan

Sometimes a person’s enrollment in the plan is retroactive. (Retroactive means that the first day of their

enrollment has already passed. The enrollment date may even have occurred last year.) If you were

retroactively enrolled in our plan and you paid out of pocket for any of your drugs after your enrollment

date, you can ask us to pay you back for our share of the costs. You will need to submit paperwork for us

to handle the reimbursement.



Please call Customer Service for additional information about how to ask us to pay you back and

deadlines for making your request. Phone numbers for Customer Service are listed on the back of

your member ID card.

5. In a medical emergency

We will cover prescriptions that are filled at an out-of-network pharmacy if the prescriptions are related

to care for a medical emergency or urgently needed care. Save your pharmacy prescription receipt and

send a copy to us when you ask us to pay you back for our share of the cost.

6. When traveling away from our plan’s service area

If you take a prescription drug on a regular basis and you are going on a trip, be sure to check your

supply of the drug before you leave. You may be able to order your prescription drugs ahead of time

through our home delivery pharmacy service. If you are traveling within the United States and need to fill

a prescription because you become ill or you lose or run out of your covered medications, we will cover

prescriptions that are filled at an out-of-network pharmacy if you follow all other coverage rules. Prior to

filling your prescription at an out-of-network pharmacy, call the Customer Service numbers listed on the

back of your member ID card to find out if there is a network pharmacy in the area where you are

traveling. If there are no network pharmacies in that area, Customer Service may be able to make

arrangements for you to get your prescriptions from an out-of-network pharmacy. We cannot pay for any

prescriptions that are filled outside the United States, even for a medical emergency.

7. To obtain a covered drug in a timely manner

In some cases, you may be unable to obtain a covered drug in a timely manner within our service area. If

there is no network pharmacy within a reasonable driving distance that provides 24-hour service, we will

cover your prescription at an out-of-network pharmacy. Save your pharmacy prescription receipt and

send a copy to us when you ask us to pay you back for our share of the cost.

8. If a network pharmacy does not stock a covered drug

Some covered prescription drugs (including orphan drugs or other specialty pharmaceuticals) may not be

regularly stocked at an accessible network retail pharmacy or through our home delivery pharmacy. We

will cover prescriptions at an out-of-network pharmacy under these circumstances. Save your pharmacy

prescription receipt and send a copy to us when you ask us to pay you back for our share of the cost.

All of the examples above are types of coverage decisions. This means that if we deny your request for

payment, you can appeal our decision. Chapter 7 has information about how to make an appeal.

SECTION 2 How to ask us to pay you back

Section 2.1 How and where to send us your request for payment

Send us your request for payment, along with a copy of your pharmacy prescription receipt or your

pharmacy patient history printout signed by the dispensing pharmacist. A copy of an invoice (bill) is

required for all other requests for payment, such as claims for vaccines from a physician or claims for

Medicare Part D drugs from a hospital or clinic. It’s a good idea to keep the original receipts or invoices, or to make copies, for your records.

To make sure you are giving us all the information we need to make a decision, you can fill out our claim

form to make your request for payment.

You don’t have to use the form, but it will help us process the information faster.

Either download a copy of the form from our website, http://www.Express-Scripts.com, or call

Customer Service and ask for a “Direct Claim Form.” The phone numbers for Customer Service are

listed on the back of your member ID card.



Mail your request for payment, together with any receipts, to us at this address:

Express Scripts

Attn: Medicare Part D

P.O. Box 14718

Lexington, KY 40512-4718

You also have the option of faxing your claim form and receipts to 1.608.741.5483.

You must submit your claim to us within 36 months of the date you received the service, item or drug.

Please be sure to contact Customer Service if you have any questions. Phone numbers for Customer Service

are listed on the back of your member ID card. If you don’t know what you should have paid, we can help.

You can also call if you want to give us more information about a request for payment you have already sent

to us.

SECTION 3 We will review your request for payment and say yes or no

Section 3.1 We check to see whether we should cover the drug and how much we owe

When we receive your request for payment, we will let you know if we need any additional information

from you. Otherwise, we will consider your request and make a coverage decision.

If we decide that the drug is covered and you followed all the rules for getting the drug, we will pay

for our share of the cost. We will mail your reimbursement of our share of the cost to you.

(Chapter 3 explains the rules you need to follow for getting your Part D prescription drugs covered.)

We will send payment within 14 days after your request was received.

If we decide that the drug is not covered, or you did not follow all the rules, we will not pay for our

share of the cost. Instead, we will send you a letter that explains the reasons why we are not sending

the payment you have requested and your rights to appeal that decision.

Section 3.2 If we tell you that we will not pay for all or part of the drug, you can make an appeal

If you think we have made a mistake in turning down your request for payment or you don’t agree with the

amount we are paying, you can make an appeal. If you make an appeal, it means you are asking us to

change the decision we made when we turned down your request for payment.

For the details on how to make this appeal, go to Chapter 7. The appeals process is a formal process with

detailed procedures and important deadlines. If making an appeal is new to you, you will find it helpful to

start by reading Section 4 of Chapter 7. Section 4 is an introductory section that explains the process for

coverage decisions and appeals and gives definitions of terms such as “appeal.” Then, after you have read

Section 4, you can go to Section 5.5 in Chapter 7 for a step-by-step explanation of how to file an appeal.

SECTION 4 Other situations in which you should save your receipts and send copies to us

Section 4.1 In some cases, you should send copies of your receipts to us to help us track your

out-of-pocket drug costs

There are some situations when you should let us know about payments you have made for your drugs. In

these cases, you are not asking us for payment. Instead, you are telling us about your payments so that we

can calculate your out-of-pocket costs correctly. This may help you to qualify for the Catastrophic Coverage

stage more quickly.



Here are two situations when you should send us copies of receipts to let us know about payments you have

made for your drugs:

1. When you buy the drug for a price that is lower than our price

Sometimes when you are in the Deductible stage and/or Coverage Gap stage (if they apply to your plan),

you may be able to buy your drug at a network pharmacy for a price that is lower than our price.

For example, a pharmacy might offer a special price on the drug. Or you may have a discount

card that is outside our benefit that offers a lower price.

Unless special conditions apply, you must use a network pharmacy in these situations.

Save your receipt and send a copy to us so that we can have your out-of-pocket expenses count

toward qualifying you for the Catastrophic Coverage stage.

Please note: If you are in the Deductible stage and/or Coverage Gap stage (if they apply to your

plan and the plan does not provide coverage in the gap), we will not pay for any share of these

drug costs. But sending a copy of the receipt allows us to calculate your out-of-pocket costs

correctly and may help you qualify for the Catastrophic Coverage stage more quickly.

2. When you get a drug through a patient assistance program offered by a drug manufacturer

Some members are enrolled in a patient assistance program offered by a drug manufacturer that is outside

the plan benefits. If you get any drugs through a program offered by a drug manufacturer, you may pay a

copayment to the patient assistance program.

Save your receipt and send a copy to us so that we can have your out-of-pocket expenses count

toward qualifying you for the Catastrophic Coverage stage.

Please note: Because you are getting your drug through the patient assistance program and not

through the plan’s benefits, we will not pay for any share of these drug costs. But sending a copy

of the receipt allows us to calculate your out-of-pocket costs correctly and may help you qualify

for the Catastrophic Coverage stage more quickly.

Since you are not asking for payment in the two cases described above, these situations are not considered

coverage decisions. Therefore, you cannot make an appeal if you disagree with our decision.


Chapter 6: Your rights and responsibilities 54

Chapter 6. Your rights and responsibilities

SECTION 1 Our plan must honor your rights as a member

Section 1.1 We must provide information in a way that works for you (in languages other than

English, in braille or in other alternate formats, etc.)

To get information from us in a way that works for you, please call Customer Service (phone numbers are

listed on the back of your member ID card).

Our plan has people and free language interpreter services available to answer questions from

non-English-speaking members. We can also give you information in braille or other alternate formats if

you need it. If you are eligible for Medicare because of a disability, we are required to give you

information about the plan’s benefits that is accessible and appropriate for you.

If you have any trouble getting information from our plan because of problems related to language or a

disability, please call Medicare at 1.800.MEDICARE (1.800.633.4227), 24 hours a day, 7 days a week and

tell them that you want to file a complaint. TTY users, call 1.877.486.2048.

Sección 1.1 Debemos brindar información de tal forma que le sea útil (en español, en braille,

o otros formatos alternativos, etc.)

Para obtener información nuestra de tal forma que le sea útil, llame al Servicio al cliente (los números de

teléfono se encuentran al dorso de su tarjeta de ID de miembro).

Nuestro plan cuenta con servicios disponibles de intérprete de idiomas sin cargo y personas para responder

preguntas de miembros que no hablan inglés. Además, podemos brindarle información en braille u otros

formatos alternativos si a necesita. Si es elegible para Medicare debido a una incapacidad, debemos

brindarle información sobre los beneficios del plan que es accesible y adecuado para usted.

Si tiene problemas para obtener información de nuestro plan debido a problemas relacionados con el idioma

o incapacidad, llame a Medicare al 1.800.MEDICARE (1.800.633.4227), las 24 horas del día, los

7 días de la semana, e infórmeles que desea presentar una queja. Los usuarios de TTY deben llamar al

1.877.486.2048.

Section 1.2 We must treat you with fairness and respect at all times

Our plan must obey laws that protect you from discrimination or unfair treatment. We do not discriminate

based on a person’s race, ethnicity, national origin, religion, gender, age, mental or physical disability, health

status, claims experience, medical history, genetic information, evidence of insurability or geographic

location within the service area.

If you want more information or have concerns about discrimination or unfair treatment, please call the

Department of Health and Human Services’ Office for Civil Rights at 1.800.368.1019 for recorded

information (TTY users, call 1.800.537.7697). You can also visit their website at http://www.hhs.gov/ocr/

or contact your regional Office for Civil Rights.

If you have a disability and need help with access to care, please call us at Customer Service (phone

numbers are listed on the back of your member ID card). If you have a complaint, such as a problem with

wheelchair access, Customer Service can help.



Section 1.3 We must ensure that you get timely access to your covered drugs

As a member of our plan, you have the right to get your prescriptions filled or refilled at any of our network

pharmacies without long delays. If you think that you are not getting your Part D drugs within a reasonable

amount of time, Chapter 7, Section 7 tells what you can do. (If we have denied coverage for your

prescription drugs and you don’t agree with our decision, Chapter 7, Section 4 tells what you can do.)

Section 1.4 We must protect the privacy of your personal health information

Federal and state laws protect the privacy of your medical records and personal health information. We

protect your personal health information as required by these laws.

Your personal health information includes the personal information you gave us when you enrolled

in this plan, as well as your medical records and other medical and health information.

The laws that protect your privacy give you rights related to getting information and controlling how

your health information is used. We give you a written notice, called a Notice of Privacy Practices,

that tells about these rights and explains how we protect the privacy of your health information.

How do we protect the privacy of your health information?

We make sure that unauthorized people don’t see or change your records.

In most situations, if we give your health information to anyone who isn’t providing your care or

paying for your care, we are required to get written permission from you first. Written permission

can be given by you or by someone you have given legal power to make decisions for you.

There are certain exceptions that do not require us to get your written permission first. These

exceptions are allowed or required by law.

o For example, we are required to release health information to government agencies that are

checking on quality of care.

o Because you are a member of our plan through Medicare, we are required to give Medicare

your health information, including information about your Part D prescription drugs. If

Medicare releases your information for research or other uses, this will be done according to

Federal statutes and regulations.

You can see the information in your records and know how it has been shared with others

You have the right to look at your medical records held by the plan and to get a copy of your records. You

also have the right to ask us to make additions or corrections to your medical records. If you ask us to do

this, we will work with your doctor to decide whether the changes should be made. You have the right to

know how your health information has been shared with others for any purposes that are not routine. If you

have questions or concerns about the privacy of your personal health information, please call Customer

Service (phone numbers are listed on the back of your member ID card).

Section 1.5 We must give you information about the plan, its network of pharmacies and your

covered drugs

As a member of Express Scripts Medicare, you have the right to get several kinds of information from us.

(As explained in Section 1.1, you also have the right to get information from us in a way that works for you.

This includes getting the information in languages other than English, in braille or in other alternate

formats.)



If you want any of the following kinds of information, please call Customer Service (phone numbers are

listed on the back of your member ID card):

Information about our plan

This includes, for example, information about the plan’s financial condition. It also includes

information about the number of appeals made by members.

Information about our network pharmacies o For example, you have the right to get information from us about the pharmacies

in our network.

o For a list of the retail pharmacies in your area and others that are in the plan’s network, see

the Pharmacy Directory.

o For more detailed information about our pharmacies, you can call Customer Service (phone

numbers are listed on the back of your member ID card) or visit our website at

http://www.Express-Scripts.com.

Information about your coverage and rules you must follow when using your coverage

o To get the details on your Part D prescription drug coverage, see Chapters 3 and 4, plus the

plan’s 2017 Formulary (List of Covered Drugs). These chapters, together with the 2017

Formulary (List of Covered Drugs), tell you what drugs are covered and explain the rules

you must follow and the restrictions to your coverage for certain drugs.

o If you have questions about the rules or restrictions, please call Customer Service (phone

numbers are listed on the back of your member ID card).

Information about why something is not covered and what you can do about it

o If your coverage is restricted in some way, you can ask us for a written explanation. You have

the right to this explanation even if you received the drug from an out-of-network pharmacy.

o If you are not happy, or if you disagree with a decision we make about how a Part D drug is

covered for you, you have the right to make an appeal and ask us to change the decision. For

details on what to do if something is not covered for you in the way you think it should be

covered, see Chapter 7. It gives you the details about how to make an appeal if you want us

to change our decision. (Chapter 7 also tells about how to make a complaint about quality of

care, waiting times and other concerns.)

o If you want to ask our plan to pay our share of the cost for a Part D prescription drug, see

Chapter 5.

Section 1.6 We must support your right to make decisions about your care

You have the right to give instructions about what is to be done if you are not able to make medical

decisions for yourself

Sometimes people become unable to make healthcare decisions for themselves due to accidents or serious

illness. You have the right to say what you want to happen if you are in this situation. This means that, if you

want to, you can:

Fill out a written form to give someone the legal authority to make medical decisions for you if

you ever become unable to make decisions for yourself.

Give your doctors written instructions about how you want them to handle your medical care if

you become unable to make decisions for yourself.



The legal documents that you can use to give your directions in advance in these situations are called

advance directives. There are different types of advance directives and different names for them.

Documents called a living will and a power of attorney for healthcare are examples of

advance directives.

If you want to use an advance directive to give your instructions, here is what to do:

Get the form. If you want to have an advance directive, you can get a form from your lawyer, from

a social worker or from some office supply stores. You can sometimes get advance directive forms

from organizations that give people information about Medicare.

Fill it out and sign it. Regardless of where you get this form, keep in mind that it is a legal

document. You should consider having a lawyer help you prepare it.

Give copies to appropriate people. You should give a copy of the form to your doctor and to the

person you name on the form as the one to make decisions for you if you can’t. You may want to

give copies to close friends or family members as well. Be sure to keep a copy at home.

If you know ahead of time that you are going to be hospitalized and you have signed an advance directive,

take a copy with you to the hospital.

If you are admitted to the hospital, they will ask you whether you have signed an advance directive

form and whether you have it with you.

If you have not signed an advance directive form, the hospital has forms available and will ask if you

want to sign one.

Remember, it is your choice whether you want to fill out an advance directive (including whether you

want to sign one if you are in the hospital). According to law, no one can deny you care or discriminate

against you based on whether or not you have signed an advance directive.

What if your instructions are not followed?

If you have signed an advance directive and you believe that a doctor or hospital hasn’t followed the

instructions in it, you may file a complaint with the appropriate agency in your state, such as the Department

of Health.

Section 1.7 You have the right to make complaints and to ask us to reconsider decisions

we have made

If you have any problems or concerns about your covered services or care, Chapter 7 tells what you can do.

It gives the details about how to deal with all types of problems and complaints.

What you need to do to follow up on a problem or concern depends on the situation. You might need to ask

our plan to make a coverage decision for you, make an appeal to us to change a coverage decision or make a

complaint. Whatever you do—ask for a coverage decision, make an appeal or make a complaint—we are

required to treat you fairly.

You have the right to get a summary of information about the appeals and complaints that other members

have filed against our plan in the past. To get this information, please call Customer Service (phone numbers

are listed on the back of your member ID card).



Section 1.8 What can you do if you think you are being treated unfairly or your rights are not being

respected?

If it is about discrimination, call the Office for Civil Rights

If you think you have been treated unfairly or your rights have not been respected due to your race,

disability, religion, sex, health, ethnicity, creed (beliefs), age or national origin, you should call the

Department of Health and Human Services’ Office for Civil Rights at 1.800.368.1019 for recorded

information (TTY users, call 1.800.537.7697). You can also visit their website at http://www.hhs.gov/ocr/ or

contact your regional Office for Civil Rights.

Is it about something else?

If you think you have been treated unfairly or your rights have not been respected and it’s not about

discrimination, you can get help dealing with the problem you are having:

You can call Customer Service (phone numbers are listed on the back of your member ID card).

You can call the State Health Insurance Assistance Program. For details about this organization,

go to Chapter 2; for information on how to contact it, go to the Appendix.

Or you can call Medicare at 1.800.MEDICARE (1.800.633.4227), 24 hours a day, 7 days a week.

TTY users should call 1.877.486.2048.

Section 1.9 How to get more information about your rights

There are several places where you can get more information about your rights:


You can call the State Health Insurance Assistance Program. For details about this organization,

go to Chapter 2; for information on how to contact it, go to the Appendix.

You can contact Medicare.

o You can visit the Medicare website to read or download the publication, “Your Medicare

Rights and Protections.” (The publication is available at:

http://www.medicare.gov/Pubs/pdf/11534.pdf.)

o Or you can call 1.800.MEDICARE (1.800.633.4227), 24 hours a day, 7 days a week.

TTY users should call 1.877.486.2048.

SECTION 2 You have some responsibilities as a member of the plan

Section 2.1 What are your responsibilities?

Things you need to do as a member of the plan are listed below. If you have any questions, please call

Customer Service (phone numbers are listed on the back of your member ID card). We’re here to help.

Get familiar with your covered drugs and the rules you must follow to get these covered drugs.

Use this Evidence of Coverage along with your formulary and other plan documents you have

received to learn what’s covered and the rules you need to follow to get your covered drugs.

o Chapters 3 and 4 give the details about your coverage for Part D prescription drugs.

If you have any other prescription drug coverage in addition to our plan, you are required to tell

us. Please call Customer Service to let us know (phone numbers are listed on the back of your

member ID card).

o We are required to follow rules set by Medicare to make sure that you are using all of your

coverage in combination when you get your covered drugs from our plan. This is called

coordination of benefits because it involves coordinating the drug benefits you get from our



plan with any other drug benefits available to you. We’ll help you coordinate your benefits.

(For more information about coordination of benefits, go to Chapter 1, Section 7.)

Tell your doctor and pharmacist that you are enrolled in our plan. Show your member ID card

whenever you get your Part D prescription drugs.

Help your doctors and other providers help you by giving them information, asking

questions and following through on your care.

o To help your doctors and other healthcare providers give you the best care, learn as much as

you are able to about your health problems and give them the information they need about

you and your health. Follow the treatment plans and instructions that you and your doctors

agree upon.

o Make sure your doctors know all of the drugs you are taking, including over-the-counter

drugs, vitamins and supplements.

o If you have any questions, be sure to ask. Your doctors and other healthcare providers are

supposed to explain things in a way you can understand. If you ask a question and you don’t

understand the answer you are given, ask again.

Pay what you owe. As a plan member, you are responsible for these payments:

o If you are responsible for a premium, you must pay it to continue being a member

of this plan.

o For most of your drugs covered by the plan, you must pay your share of the cost when you

get the drug. This will be a copayment (a fixed amount) or coinsurance (a percentage of the

total cost). Your Benefit Overview or Annual Notice of Changes will tell you what you must

pay for your Part D prescription drugs.

o If you get any drugs that are not covered by our plan or by other insurance you may have,

you must pay the full cost.

o If you disagree with our decision to deny coverage for a drug, you can make an appeal.

Please see Chapter 7 for information about how to make an appeal.

o If you are required to pay a late enrollment penalty (LEP), you must pay the penalty to

remain a member of the plan.

o If you are required to pay the extra amount for Part D because of your yearly income, you

must pay the extra amount directly to the government to remain a member of the plan.

Tell us if you move. If you are going to move, it’s important to tell us right away. Call your group

benefits administrator.

o If you move outside of our plan service area, you cannot remain a member of our plan. (Chapter 1 tells about our service area.)

o If you move within our service area, we still need to know so we can keep your

membership record up to date and know how to contact you.

o If you move, it is also important to tell Social Security. You can find the phone numbers and

contact information for Social Security in Chapter 2.

Call Customer Service for help if you have questions or concerns. We also welcome any

suggestions you may have for improving our plan.

o Phone numbers for Customer Service are listed on the back of your member ID card.

o For more information on how to reach us, including our mailing address, please see

Chapter 2.


Chapter 7: What to do if you have a problem or complaint

(coverage decisions, appeals, complaints) 60

Chapter 7. What to do if you have a problem or complaint

(coverage decisions, appeals, complaints)

Background


Section 1.1 What to do if you have a problem or concern

This chapter explains two types of processes for handling problems and concerns:

One for coverage decisions and making appeals

And another process for making complaints

Both of these processes have been approved by Medicare. To ensure fairness and prompt handling of your

problems, each process has a set of rules, procedures and deadlines that must be followed by us and by you.

Which one do you use? That depends on the type of problem you are having. The guide in Section 3 will

help you identify the right process to use.

Section 1.2 What about the legal terms?

There are technical legal terms for some of the rules, procedures and types of deadlines

explained in this chapter. Many of these terms are unfamiliar to most people and can be hard

to understand.

To keep things simple, this chapter explains the legal rules and procedures using simpler words in place of

certain legal terms. For example, this chapter generally says “making a complaint” rather than “filing a

grievance,” “coverage decision” rather than “coverage determination,” and “Independent Review

Organization” instead of “Independent Review Entity.” It also uses abbreviations as little as possible.

However, it can be helpful—and sometimes quite important—for you to know the correct legal terms for the

situation you are in. Knowing which terms to use will help you communicate more clearly and accurately

when you are dealing with your problem and get the right help or information for your situation. To help

you know which terms to use, we include legal terms when we give the details for handling specific types of

situations.

SECTION 2 You can get help from government organizations that are not connected with us

Section 2.1 Where to get more information and personalized assistance

Sometimes it can be confusing to start or follow through with the process for dealing with a problem. This

can be especially true if you do not feel well or have limited energy. Other times, you may not have the

knowledge you need to take the next step.




Get help from an independent government organization

We are always available to help you. But in some situations you may also want help or guidance from

someone who is not connected to us. You can always contact your State Health Insurance Assistance

Program (SHIP). This government program has trained counselors in every state. The program is not

connected with us or with any insurance company or health plan. The counselors at this program can help

you understand which process you should use to handle a problem you are having. They can also answer

your questions, give you more information and offer guidance on what to do.

The services of SHIP counselors are free. You will find phone numbers in the Appendix.

You can also get help and information from Medicare

For more information and help in handling a problem, you can also contact Medicare. Here are two ways

to get information directly from Medicare:

You can call 1.800.MEDICARE (1.800.633.4227), 24 hours a day, 7 days a week. TTY users

should call 1.877.486.2048.

You can visit the Medicare website (http://www.medicare.gov).

SECTION 3 To deal with your problem, which process should you use?

Section 3.1 Should you use the process for coverage decisions and appeals?

Or should you use the process for making complaints?

If you have a problem or concern, read the parts of this chapter that apply to your situation. The guide below

will help.

To figure out which part of this chapter will help with your specific problem or concern,

START HERE

Is your problem or concern about your benefits or coverage? (This includes problems about whether particular prescription drugs are covered or not, the way in

which they are covered and problems related to payment for prescription drugs.)

Yes.

My problem is about

benefits or coverage.

Go on to the next section of this chapter,

Section 4: A guide to the basics of

coverage decisions and appeals.

No.

My problem is not about

benefits or coverage.

Skip ahead to Section 7 at the end of this chapter:

How to make a complaint about quality of care,

waiting times, customer service or other concerns.




Coverage decisions and appeals

SECTION 4 A guide to the basics of coverage decisions and appeals

Section 4.1 Asking for coverage decisions and making appeals: the big picture

The process for coverage decisions and appeals deals with problems related to your benefits and coverage

for prescription drugs, including problems related to payment. This is the process you use for issues such

as whether a drug is covered or not and the way in which the drug is covered.

Asking for coverage decisions

A coverage decision is a decision we make about your benefits and coverage or about the amount we will

pay for your prescription drugs.

We are making a coverage decision for you whenever we decide what is covered for you and how much we

pay. In some cases, we might decide a drug is not covered or is no longer covered by Medicare for you. If

you disagree with this coverage decision, you can make an appeal.

Making an appeal

If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision.

An appeal is a formal way of asking us to review and change a coverage decision we have made.

When you appeal a decision for the first time, this is called a Level 1 Appeal. In this appeal, we review the

coverage decision we have made to check to see if we were following all of the rules properly. Your appeal

is handled by different reviewers than those who made the original unfavorable decision. When we have

completed the review, we give you our decision. Under certain circumstances, which we discuss later, you

can request an expedited or “fast coverage decision” or fast appeal of a coverage decision.

If we say no to all or part of your Level 1 Appeal, you can ask for a Level 2 Appeal. The Level 2 Appeal is

conducted by an independent organization that is not connected to us. If you are not satisfied with the

decision at the Level 2 Appeal, you may be able to continue through additional levels of appeal.

Section 4.2 How to get help when you are asking for a coverage decision or making

an appeal

Would you like some help? Here are resources you may wish to use if you decide to ask for any kind of

coverage decision or appeal a decision:

You can call us at Customer Service (phone numbers are listed on the back of your member ID

card).

To get free help from an independent organization that is not connected with our plan, contact

your State Health Insurance Assistance Program (see Section 2 of this chapter for more

information).

For your Part D prescription drugs, your doctor or other prescriber can request a coverage

decision or a Level 1 or 2 Appeal on your behalf. To request any appeal after Level 2, your doctor or

other provider must be appointed as your representative.




You can ask someone to act on your behalf. If you want to, you can name another person to act for

you as your representative to ask for a coverage decision or make an appeal.

o There may be someone who is already legally authorized to act as your representative under

State law.

o If you want a friend, relative, your doctor or other prescriber or any other person to be your

representative, call Customer Service (phone numbers for Customer Service are listed on the

back of your member ID card) and ask for the “Appointment of Representative” form. (The

form is also available on Medicare’s website at

http://www.cms.hhs.gov/cmsforms/downloads/cms1696.pdf.) The “Appointment of

Representative” form gives that person permission to act on your behalf. It must be signed

by you and by the person whom you would like to act on your behalf. You must give us a

copy of the signed form.

You also have the right to hire a lawyer to act for you. You may contact your own lawyer or

get the name of a lawyer from your local bar association or other referral service. There are also

groups that will give you free legal services if you qualify. However, you are not required to

hire a lawyer to ask for any kind of coverage decision or appeal a decision.

SECTION 5 Your Part D prescription drugs: How to ask for a coverage decision or make an

appeal

? Have you read Section 4 of this chapter, A guide to the basics of coverage

decisions and appeals? If not, you may want to read it before you start

this section.

Section 5.1 This section tells you what to do if you have problems getting a Part D drug or you want

us to pay you back for a Part D drug

Your benefits as a member of our plan include coverage for many prescription drugs. Please refer to the

2017 Formulary (List of Covered Drugs). To be covered, the drug must be used for a medically accepted

indication. (A “medically accepted indication” is a use of the drug that is either approved by the FDA or

supported by certain reference books. See Chapter 3, Section 3 for more information about a medically

accepted indication.)

This section is about your Part D drugs only. To keep things simple, we generally say “drug” in

the rest of this section, instead of repeating “covered outpatient prescription drug” or “Part D drug”

every time.

For details about what we mean by Part D drugs, the 2017 Formulary (List of Covered Drugs), rules

and restrictions on coverage and cost information, see Chapter 3 and Chapter 4.

Part D coverage decisions and appeals

As discussed in Section 4 of this chapter, a coverage decision is a decision we make about your benefits and

coverage or about the amount we will pay for your drugs.

Legal

terms

An initial coverage decision about your Part D drugs is called a coverage

determination.




Here are examples of coverage decisions you may ask us to make about your Part D drugs:

You ask us to make an exception, including:

o Asking us to waive a restriction on the plan’s coverage for a drug (such as limits on the

amount of the drug you can get)

o Asking to pay a lower cost-sharing amount for a covered drug on a higher cost-sharing tier

You ask us whether a drug is covered for you and whether you satisfy any applicable coverage rules.

(For example, when your drug is covered by the plan, but we require you to get approval from us

before we will cover it for you.)

o Please note: If your pharmacy tells you that your prescription cannot be filled as written, you

will get a written notice from the pharmacy explaining how to contact us to ask for a

coverage decision.

You ask us to pay for a prescription drug you already bought. This is a request for a coverage

decision about payment.

If you disagree with a coverage decision we have made, you can appeal our decision.

This section tells you both how to ask for coverage decisions and how to request an appeal. Use the chart

below to help you determine which part has information for your situation:

Section 5.2 What is an exception?

If a drug is not covered in the way you would like it to be covered, you can ask us to make an “exception.”

An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down

your request for an exception, you can appeal our decision.

Which of these situations are you in?

Do you want us

to waive a rule or

restriction on a

drug we cover?

Do you believe you have

met any plan rules or

restrictions (such as

getting approval in

advance) for the drug

you need?

Do you want to ask

us to pay you back

for a drug you have

already received and

paid for?

Have we already told

you that we will not

cover or pay for a

drug in the way that

you want it to be

covered or paid for?

You can ask us to

make an

exception. (This is

a type of coverage

decision.)

You can ask us for a

coverage decision.

You can ask us to pay

you back.

(This is a type of

coverage decision.)

You can make an appeal.

(This means you are

asking us to reconsider.)

Start with Section

5.2 of this chapter.

Skip ahead to Section 5.4

of this chapter.

Skip ahead to Section


Skip ahead to Section





When you ask for an exception, your doctor or other prescriber will need to explain the medical reasons

why you need the exception approved. We will then consider your request. Here are examples of exceptions

that you or your doctor or other prescriber can ask us to make:

1. Removing a restriction on our coverage for a covered drug. There are extra rules or restrictions that

apply to certain drugs we cover (for more information, go to Chapter 3).

Legal

terms

Asking for removal of a restriction on coverage for a drug is sometimes called asking

for an exception.

The extra rules and restrictions on coverage for certain drugs include:

o Getting plan approval in advance before we will agree to cover the drug for you. (This is

sometimes called prior authorization.)

o Being required to try a different drug first before we agree to cover the drug you are

asking for. (This is sometimes called step therapy.)

o Quantity limits. For some drugs, there are restrictions on the amount of the drug you can

have.

If we agree to make an exception and waive a restriction for you, you can ask for an exception to

the copayment or coinsurance amount we require you to pay for the drug.

2. Changing coverage of a drug to a lower cost-sharing tier. Every drug on our Drug List is in a specific

cost-sharing tier. You can see what tier a drug is in by looking in your 2017 Formulary (List of Covered

Drugs). In general, the lower the cost-sharing tier number, the less you will pay as your share of the cost

of the drug.

Legal

terms

Asking to pay a lower preferred price for a covered non-preferred drug is sometimes called

asking for a tiering exception.

If your plan has a Non-Preferred Drug Tier and a Preferred Brand Tier and if your drug is in a

Non-Preferred Drug Tier, you can ask us to cover it at a lower cost-sharing amount that applies

to drugs in a Preferred Brand Tier. This would lower your share of the cost for the drug.

If your plan has a Non-Preferred Generic Tier and a Preferred Generic Tier and if your drug is in

a Non-Preferred Generic Tier, you can ask us to cover it at a lower cost-sharing amount that

applies to drugs in a Preferred Generic Tier. This would lower your share of the cost for the drug.

If your plan has a Specialty Tier, you may not be able to change the cost-sharing tier for any

drugs in this tier.

Section 5.3 Important things to know about asking for exceptions

Your doctor must tell us the medical reasons

Your doctor or other prescriber must give us a statement that explains the medical reasons for requesting an

exception. For a faster decision, include this medical information from your doctor or other prescriber when

you ask for the exception.




Typically, our plan’s coverage includes more than one drug for treating a particular condition. These

different possibilities are called “alternative” drugs. If an alternative drug would be just as effective as the

drug you are requesting and would not cause more side effects or other health problems, we will generally

not approve your request for an exception. If you ask us for a tiering exception, we will generally not

approve your request for an exception unless the alternative drugs in the lower cost-sharing tier(s) won’t

work as well for you.

We can say yes or no to your request

If we approve your request for an exception, our approval is typically valid for 12 months. This is

true as long as your doctor continues to prescribe the drug for you and that drug continues to be safe

and effective for treating your condition.

If we say no to your request for an exception, you can ask for a review of our decision by making an

appeal. Section 5.5 tells you how to make an appeal if we say no.

The next section tells you how to ask for a coverage decision, including an exception.

Section 5.4 Step-by-step: How to ask for a coverage decision, including an exception

Step 1 You ask us to make a coverage decision about the drug(s) or payment you need. If your

health requires a quick response, you must ask us to make a “fast coverage decision.” You

cannot ask for a fast coverage decision if you are asking us to pay you back for a drug

you already bought.

What to do

Request the type of coverage decision you want. Start by calling, writing or faxing us to make

your request. You, your authorized representative or your doctor (or other prescriber) can do this.

You can also access information about the coverage decision process through our Web site. For the

details, go to Chapter 2, Section 1 and look for the section called How to contact us when you are

asking for a coverage decision or an appeal about your Part D prescription drugs. Or if you are

asking us to pay you back for a drug, go to the section called Where to send a request asking us to

pay for our share of the cost of a drug you have received.

You or your doctor or someone else who is acting on your behalf can ask for a coverage

decision. Section 4 of this chapter tells how you can give written permission to someone else to act

as your authorized representative. You can also have a lawyer act on your behalf.

If you want to ask us to pay you back for a drug, start by reading Chapter 5, which describes

the situations in which you may need to ask for reimbursement. It also tells how to send us the

paperwork that asks us to pay you back for our share of the cost of a drug you have paid for.

If you are requesting an exception, provide the supporting statement. Your doctor or other

prescriber must give us the medical reasons for the drug exception you are requesting. (We call this

the “supporting statement.”) Your doctor or other prescriber can fax or mail the statement to us. Or

your doctor or other prescriber can tell us on the phone and follow up by faxing or mailing a

written statement if necessary. See Sections 5.2 and 5.3 for more information about exception

requests.




We must accept any written request, including a request submitted on the CMS Model Coverage

Determination Request Form, which is available on our website at www.Express-Scripts.com.

If your health requires it, ask us to give you a fast coverage decision

Legal

terms A fast coverage decision is called an expedited coverage determination.

When we give you our coverage decision, we will use the “standard” deadlines unless we have

agreed to use the “fast” deadlines. A standard coverage decision means we will give you an answer

within 72 hours after we receive your doctor’s statement. A fast coverage decision means we will

answer within 24 hours after we receive your doctor’s statement.

To get a fast coverage decision, you must meet two requirements:

o You can get a fast coverage decision only if you are asking for a drug you have not yet

received. (You cannot get a fast coverage decision if you are asking us to pay you back for a

drug you have already bought.)

o You can get a fast coverage decision only if using the standard deadlines could cause serious

harm to your health or hurt your ability to function.

If your doctor or other prescriber tells us that your health requires a fast coverage decision,

we will automatically agree to give you a fast coverage decision.

If you ask for a fast coverage decision on your own (without your doctor’s or other prescriber’s

support), we will decide whether your health requires that we give you a fast coverage decision.

o If we decide that your medical condition does not meet the requirements for a fast coverage

decision, we will send you a letter that says so (and we will use the standard deadlines

instead).

o This letter will tell you that if your doctor or other prescriber asks for the fast coverage

decision, we will automatically give a fast coverage decision.

o The letter will also tell how you can file a complaint about our decision to give you a

standard coverage decision instead of the fast coverage decision you requested. It tells how to

file a “fast” complaint, which means you would get our answer to your complaint within

24 hours of receiving the complaint. (The process for making a complaint is different from

the process for coverage decisions and appeals. For more information about the process for

making complaints, see Section 7 of this chapter.)

Step 2 We consider your request and we give you our answer.

Deadlines for a fast coverage decision

If we are using the fast deadlines, we must give you our answer within 24 hours.

o Generally, this means within 24 hours after we receive your request. If you are requesting an

exception, we will give you our answer within 24 hours after we receive your doctor’s

statement supporting your request. We will give you our answer sooner if your health

requires us to.

o If we do not meet this deadline, we are required to send your request on to Level 2 of the

appeals process, where it will be reviewed by an independent outside organization. Later in

this section, we talk about this review organization and explain what happens at Appeal

Level 2.




If our answer is yes to part or all of what you requested, we must provide the coverage we have

agreed to provide within 24 hours after we receive your request or doctor’s statement supporting

your request.

If our answer is no to part or all of what you requested, we will send you a written statement

that explains why we said no. We will also tell you how to appeal the decision.

Deadlines for a standard coverage decision about a drug you have not yet received

If we are using the standard deadlines, we must give you our answer within 72 hours.

o Generally, this means within 72 hours after we receive your request. If you are requesting an

exception, we will give you our answer within 72 hours after we receive your doctor’s

statement supporting your request. We will give you our answer sooner if your health

requires us to.


appeals process, where it will be reviewed by an independent organization. Later in this

section, we talk about this review organization and explain what happens at Appeal Level 2.

If our answer is yes to part or all of what you requested – o If we approve your request for coverage, we must provide the coverage we have agreed to

provide within 72 hours after we receive your request or doctor’s statement supporting your

request.


that explains why we said no. We will also tell you how to appeal the decision.

Deadlines for a standard coverage decision about payment for a drug you have already bought

We must give you our answer within 14 calendar days after we receive your request.


appeals process, where it will be reviewed by an independent organization. Later in this

section, we talk about this review organization and explain what happens at Appeal Level 2.

If our answer is yes to part or all of what you requested, we are also required to make payment

to you within 14 calendar days after we receive your request.


that explains why we said no. We will also tell you how to appeal.

Step 3 If we say no to your coverage request, you decide if you want to make an appeal.

If we say no, you have the right to request an appeal. Requesting an appeal means asking us to

reconsider—and possibly change—the decision we made.




Section 5.5 Step-by-step: How to make a Level 1 Appeal

(how to ask for a review of a coverage decision made by our plan)

Legal

terms

An appeal to the plan about a Part D drug coverage decision is called a

plan redetermination.

Step 1 You contact us and make your Level 1 Appeal. If your health requires a quick response, you

must ask for a fast appeal.

What to do

To start your appeal, you (or your authorized representative or your doctor or other

prescriber) must contact us. o For details on how to reach us by phone, fax, or mail, or on our website for any purpose

related to your appeal, go to Chapter 2, Section 1 and look for the section called How to

contact us when you are asking for a coverage decision or an appeal about your Part D

prescription drugs.

If you are asking for a standard appeal, make your appeal by submitting a written request.

You may also ask for an appeal by calling us at the phone numbers shown in Chapter 2, Section 1

(How to contact us when you are asking for a coverage decision or an appeal about your Part D

prescription drugs.)

If you are asking for a fast appeal, you may make your appeal in writing or you may call us

at the phone numbers shown in Chapter 2, Section 1 (How to contact us when you are asking

for a coverage decision or an appeal about your Part D prescription drugs.)

We must accept any written request, including a request submitted on the CMS Model Coverage

Determination Request Form, which is available on our website.

You must make your appeal request within 60 calendar days from the date on the written

notice we sent to tell you our answer to your request for a coverage decision. If you miss this

deadline and have a good reason for missing it, we may give you more time to make your appeal.

Examples of good cause for missing the deadline may include if you had a serious illness that

prevented you from contacting us or if we provided you with incorrect or incomplete information

about the deadline for requesting an appeal.

You can ask for a copy of the information in your appeal and add more information. o You have the right to ask us for a copy of the information regarding your appeal.

o If you wish, you and your doctor or other prescriber may give us additional information to

support your appeal.

If your health requires it, ask for a fast appeal

Legal

terms A fast appeal is also called an expedited reconsideration (redetermination).

If you are appealing a decision we made about a drug you have not yet received, you and your

doctor or other prescriber will need to decide if you need a fast appeal.




The requirements for getting a fast appeal are the same as those for getting a fast decision in

Section 5.4 of this chapter.

Step 2 We consider your appeal and we give you our answer.

When we are reviewing your appeal, we take another careful look at all of the information about

your coverage request. We check to see if we were following all the rules when we said no to your

request. We may contact you or your doctor or other prescriber to get more information.

Deadlines for a fast appeal

If we are using the fast deadlines, we must give you our answer within 72 hours after we receive

your appeal request. We will give you our answer sooner if your health requires it.

o If we do not give you an answer within 72 hours, we are required to send your request on to

Level 2 of the appeals process, where it will be reviewed by an Independent Review

Organization. Later in this section, we talk about this review organization and explain what

happens at Level 2 of the appeals process.

If our answer is yes to part or all of what you requested, we must provide the coverage we have

agreed to provide within 72 hours after we receive your appeal.


that explains why we said no and how to appeal our decision.

Deadlines for a standard appeal

If we are using the standard deadlines, we must give you our answer within 7 calendar days after

we receive your appeal. We will give you our decision sooner if you have not received the drug yet

and your health condition requires us to do so. If you believe your health requires it, you should

ask for a “fast” appeal.

o If we do not give you a decision within 7 calendar days, we are required to send your request

on to Level 2 of the appeals process, where it will be reviewed by an Independent Review

Organization. Later in this section, we talk about this review organization and explain what

happens at Level 2 of the appeals process.

If our answer is yes to part or all of what you requested – o If we approve a request for coverage, we must provide the coverage we have agreed to

provide as quickly as your health requires, but no later than 7 calendar days after we

receive your appeal request.

o If we approve a request to pay you back for a drug you already bought, we are required to

send payment to you within 30 calendar days after we receive your appeal request.


that explains why we said no and how to appeal our decision.




Step 3 If we say no to your appeal, you decide if you want to continue with the appeals process and

make another appeal.

If we say no to your appeal, you then choose whether to accept this decision or continue by making

another appeal.

If you decide to make another appeal, it means your appeal is going on to Level 2 of the appeals

process (see below).

Section 5.6 Step-by-step: How to make a Level 2 Appeal

If we say no to your appeal, you then choose whether to accept this decision or continue by making another

appeal. If you decide to go on to a Level 2 Appeal, the Independent Review Organization reviews the

decision we made when we said no to your first appeal. This organization decides whether the decision we

made should be changed.

Legal

terms

The formal name for the Independent Review Organization is the Independent Review

Entity. It is sometimes called the IRE.

Step 1 To make a Level 2 Appeal, you must contact the Independent Review Organization and ask

for a review of your case.

If we say no to your Level 1 Appeal, the written notice we send you will include instructions on

how to make a Level 2 Appeal with the Independent Review Organization. These instructions

will tell who can make this Level 2 Appeal, what deadlines you must follow and how to reach the

review organization.

When you make an appeal to the Independent Review Organization, we will send the information

we have about your appeal to this organization. This information is called your “case file.” You

have the right to ask us for a copy of your case file.

You have a right to give the Independent Review Organization additional information to support

your appeal.

Step 2 The Independent Review Organization does a review of your appeal and

gives you an answer.

The Independent Review Organization is an independent organization that is hired by

Medicare. This organization is not connected with us and it is not a government agency. This

organization is a company chosen by Medicare to review our decisions about your Part D benefits

with us.

Reviewers at the Independent Review Organization will take a careful look at all of the

information related to your appeal. The organization will tell you its decision in writing and

explain the reasons for it.

Deadlines for fast appeal at Level 2

If your health requires it, ask the Independent Review Organization for a fast appeal.




If the review organization agrees to give you a fast appeal, the review organization must give you

an answer to your Level 2 Appeal within 72 hours after it receives your appeal request.

If the Independent Review Organization says yes to part or all of what you requested, we

must provide the drug coverage that was approved by the review organization within 24 hours

after we receive the decision from the review organization.

Deadlines for standard appeal at Level 2

If you have a standard appeal at Level 2, the review organization must give you an answer to your

Level 2 Appeal within 7 calendar days after it receives your appeal.

If the Independent Review Organization says yes to part or all of what you requested –

o If the Independent Review Organization approves a request for coverage, we must provide

the drug coverage that was approved by the review organization within 72 hours after we

receive the decision from the review organization.

o If the Independent Review Organization approves a request to pay you back for a drug you

already bought, we are required to send payment to you within 30 calendar days after we

receive the decision from the review organization.

What if the review organization says no to your appeal?

If this organization says no to your appeal, it means the organization agrees with our decision not to approve

your request. (This is called “upholding the decision.” It is also called “turning down your appeal.”)

If the Independent Review Organization “upholds the decision,” you have the right to a Level 3 appeal.

However, to make another appeal at Level 3, the dollar value of the drug coverage you are requesting must

meet a minimum amount. If the dollar value of the coverage you are requesting is too low, you cannot make

another appeal and the decision at Level 2 is final. The notice you get from the Independent Review

Organization will tell you the dollar value that must be in dispute to continue with the appeals process.

Step 3 If the dollar value of the coverage you are requesting meets the requirement,

you choose whether you want to take your appeal further.

There are three additional levels in the appeals process after Level 2 (for a total of five levels of

appeal).

If your Level 2 Appeal is turned down and you meet the requirements to continue with the appeals

process, you must decide whether you want to go on to Level 3 and make a third appeal. If you

decide to make a third appeal, the details on how to do this are in the written notice you got after

your second appeal.

The Level 3 Appeal is handled by an Administrative Law Judge. Section 6 in this chapter tells

more about Levels 3, 4 and 5 of the appeals process.




SECTION 6 Taking your appeal to Level 3 and beyond

Section 6.1 Levels of Appeal 3, 4 and 5 for Part D drug appeals

This section may be appropriate for you if you have made a Level 1 Appeal and a Level 2 Appeal and both

of your appeals have been turned down.

If the value of the drug you have appealed meets a certain dollar amount, you may be able to go on to

additional levels of appeal. If the dollar amount is less, you cannot appeal any further. The written response

you receive to your Level 2 Appeal will explain whom to contact and what to do to ask for a Level 3

Appeal.

For most situations that involve appeals, the last three levels of appeal work in much the same way. Here is

who handles the review of your appeal at each of these levels.

Level 3

Appeal:

A judge who works for the Federal government will review your appeal and give

you an answer. This judge is called an “Administrative Law Judge.”

If the answer is yes, the appeals process is over. What you asked for in the appeal has been

approved. We must authorize or provide the drug coverage that was approved by the

Administrative Law Judge within 72 hours (24 hours for expedited appeals) or make payment

no later than 30 calendar days after we receive the decision.

If the Administrative Law Judge says no to your appeal, the appeals process may or may not

be over. o If you decide to accept this decision that turns down your appeal, the appeals process is over.

o If you do not want to accept the decision, you can continue to the next level of the review

process. If the Administrative Law Judge says no to your appeal, the notice you get will tell

you what to do next if you choose to continue with your appeal.

Level 4

Appeal:

The Appeals Council will review your appeal and give you an answer.

The Appeals Council works for the Federal government.

If the answer is yes, the appeals process is over. What you asked for in the appeal has been

approved. We must authorize or provide the drug coverage that was approved by the Appeals

Council within 72 hours (24 hours for expedited appeals) or make payment no later than 30

calendar days after we receive the decision.

If the answer is no, the appeals process may or may not be over.

o If you decide to accept this decision that turns down your appeal, the appeals process is over.

o If you do not want to accept the decision, you might be able to continue to the next level of

the review process. If the Appeals Council says no to your appeal or denies your request to

review the appeal, the notice you get will tell you whether the rules allow you to go on to a

Level 5 Appeal. If the rules allow you to go on, the written notice will also tell you whom to

contact and what to do next if you choose to continue with your appeal.

Level 5

Appeal: A judge at the Federal District Court will review your appeal and make a decision.

This is the last step of the appeals process.




Making complaints

SECTION 7 How to make a complaint about quality of care, waiting times, customer service

or other concerns

? If your problem is about decisions related to benefits, coverage or payment,

then this section is not for you. Instead, you need to use the process for

coverage decisions and appeals. Go to Section 4 of this chapter.

Section 7.1 What kinds of problems are handled by the complaint process?

This section explains how to use the process for making complaints. The complaint process is used for

certain types of problems only. This includes problems related to quality of care, waiting times and the

customer service you receive. Here are examples of the kinds of problems handled by the complaint process.

If you have any of the following kinds of problems or concerns, you can make a complaint:

If you are unhappy with the quality of care received

If you feel someone did not respect your right to privacy or has shared information you feel

should be confidential

If you feel someone treated you disrespectfully

If you received poor customer service

If you feel you are being encouraged to leave the plan

If you were kept waiting too long at the pharmacy or by Customer Service

If you are unhappy with the condition or cleanliness of the pharmacy

If you feel we have not given you a notice we are required to give or that written information

was too difficult to understand

These types of complaints are all related to the timeliness of our actions related to coverage decisions

and appeals.

The process of asking for a coverage decision and making appeals is explained in Sections 4–6 of this

chapter. If you are asking for a decision or making an appeal, you use that process, not the complaint

process.

However, if you have already asked us for a coverage decision or made an appeal and you think that we

are not responding quickly enough, you can also make a complaint about our slowness. Here are

examples:

• If you have asked us to give you a “fast response” for a coverage decision or appeal and we have

said we will not, you can make a complaint.

• If you believe we are not meeting the deadlines for giving you a coverage decision or an answer

to an appeal you have made, you can make a complaint.

• When a coverage decision we made is reviewed and we are told that we must cover or reimburse

you for certain drugs, there are deadlines that apply. If you think we are not meeting these

deadlines, you can make a complaint.

When we do not give you a decision on time, we are required to forward your case to the Independent

Review Organization. If we do not do that within the required deadline, you can make a complaint.




Section 7.2 The formal name for making a complaint is filing a grievance

Legal

terms

What this section calls a complaint is also called a grievance.

Another term for making a complaint is filing a grievance.

Another way to say using the process for complaints is using the process

for filing a grievance.

Section 7.3 Step-by-step: Making a complaint

Step 1 Contact us promptly – either by phone or in writing.

Usually, calling Customer Service is the first step. If there is anything else you need to do,

Customer Service will let you know. Call us at the phone numbers listed on the back of your

member ID card.

If you do not wish to call (or you called and were not satisfied), you can put your complaint

in writing and send it to us. If you put your complaint in writing, we will respond to your

complaint in writing.

o If you call to make a complaint, an attempt will be made to resolve your complaint over the

phone. If we cannot resolve your complaint over the phone, we will respond within 30 days.

o If you prefer to make your complaint in writing, please send a letter with as much detail as

possible to: Express Scripts Medicare, Attn: Grievance Resolution Team, P.O. Box 3610,

Dublin, OH 43016-0307. All written complaints will be responded to within 30 days.

o If you have a grievance regarding a denial for a request for a “fast coverage decision” or a “fast

appeal,” we will give you an answer within 24 hours.

Whether you call or write, you should contact Customer Service right away. The complaint

must be made within 60 calendar days after you had the problem you want to complain about.

If you are making a complaint because we denied your request for a fast response to a

coverage decision or appeal, we will automatically give you a fast complaint. If you have a

“fast” complaint, it means we will give you an answer within 24 hours.

Legal

terms What this section calls a fast complaint is also called an expedited grievance.

Step 2 We look into your complaint and give you our answer.

If possible, we will answer you right away. If you call us with a complaint, we may be able to

give you an answer on the same phone call. If your health condition requires us to answer quickly,

we will do that.

Most complaints are answered in 30 calendar days. If we need more information and the delay

is in your best interest or if you ask for more time, we can take up to 14 more calendar days

(44 calendar days total) to answer your complaint. If we decide to take extra days, we will tell you

in writing.




If we do not agree with some or all of your complaint or don’t take responsibility for the problem

you are complaining about, we will let you know. Our response will include our reasons for this

answer. We must respond whether we agree with the complaint or not.

Section 7.4 You can also make complaints about quality of care to the

Quality Improvement Organization

You can make your complaint about the quality of care you received by using the step-by-step process

outlined above.

When your complaint is about quality of care, you also have two additional options:

You can make your complaint to the Quality Improvement Organization. If you prefer, you

can make your complaint about the quality of care you received directly to this organization

(without making the complaint to us).

o The Quality Improvement Organization is a group of practicing doctors and other healthcare

experts paid by the Federal government to check and improve the care given to Medicare

patients.

o To find the name, address and phone number of the Quality Improvement Organization for

your state, look in the Appendix. If you make a complaint to this organization, we will work

with them to resolve your complaint.

Or you can make your complaint to both at the same time. If you wish, you can make your

complaint about quality of care to us and also to the Quality Improvement Organization.

Section 7.5 You can also tell Medicare about your complaint

You can submit a complaint about Express Scripts Medicare directly to Medicare. To submit a complaint to

Medicare, go to http://www.medicare.gov/MedicareComplaintForm/home.aspx. Medicare takes your

complaints seriously and will use this information to help improve the quality of the Medicare program.

If you have any other feedback or concerns, or if you feel the plan is not addressing your issue, please call

1.800.MEDICARE (1.800.633.4227). TTY users can call 1.877.486.2048.


Chapter 8: Ending your membership in this plan 77

Chapter 8. Ending your membership in this plan

Note: This chapter contains general information on disenrollment from a Medicare Part D plan and

member options. For specific options available to you as a member of a group-sponsored plan or for

more information, please contact your group benefits administrator.


Section 1.1 This chapter focuses on ending your membership in this plan

Ending your membership in Express Scripts Medicare may be voluntary (your own choice) or involuntary

(not your own choice):

You might leave this plan because you or your group benefits administrator has decided to end

your membership. You should always check with your group benefits administrator before

leaving this plan.

o There are only certain times during the year, or certain situations, when you may voluntarily end

your membership in a Medicare Part D plan. Section 2 tells you when you can end your

membership in this plan. As a member of a group-sponsored plan (such as this plan), you

may end your membership in this plan at any time throughout the year and you will be

granted a Special Enrollment Period. Please contact your group benefits administrator for

more information before making a decision to do so to ensure that you understand any

additional implications of leaving this plan (for example, loss of medical or dental benefits).

o The process for voluntarily ending your membership varies, depending on what type of new

coverage you are choosing. Section 3 tells you how to end your membership.

There are also limited situations where you do not choose to leave, but we are required to end your

membership. Section 5 tells you about situations when we must end your membership.

If you are leaving this plan, you must continue to get your Part D prescription drugs through this plan until

your membership ends.

SECTION 2 When can you end your membership in this plan?

You may end your membership in this plan only during certain times of the year, known as enrollment

periods. All members have the opportunity to leave their plan during the Medicare Annual Enrollment

Period. In certain situations, you may also be eligible to leave this plan at other times of the year.

Section 2.1 Usually, you can end your membership during the Medicare Annual Enrollment Period

You can end your membership during the Medicare Annual Enrollment Period (also known as the Annual

Coordinated Election Period) or your former employer or your retiree group’s annual enrollment period.

This is the time when you should review your health and drug coverage and make a decision about your

coverage for the upcoming year.



When is the Medicare Annual Enrollment Period? This happens from October 15 to

December 7 every year. Your former employer or retiree group may have established an open

enrollment period with different timing during which you may elect changes. Please contact

your group benefits administrator for more information about any former employer or your

retiree group-established open enrollment periods.

o Since you are a member of a group-sponsored plan, you should contact your group

benefits administrator for information regarding any other plan options available to

you, as well as any implications of leaving this plan (such as loss of medical or

dental benefits).

When will your membership end? Your membership will end when your new plan’s coverage

begins on January 1. If you enroll in another plan during this period, your membership in this plan

will end.

Section 2.2 In certain situations, you can end your membership during a Special Enrollment Period

In certain situations, members of Express Scripts Medicare may be eligible to end their membership at other

times of the year. This is known as a Special Enrollment Period.

Who is eligible for a Special Enrollment Period? If any of the following situations apply to you,

you are eligible to end your membership during a Special Enrollment Period. These are just

examples of special enrollment periods that are available. For the full list, you can contact the plan,

call Medicare or visit the Medicare website (http://www.medicare.gov):

o If you have moved out of your plan’s service area

o If you have Medicaid

o If you are eligible for Extra Help with paying for your Medicare prescriptions

o If we violate our contract with you

o If you are getting care in an institution, such as a nursing home or long-term care (LTC)

hospital

o If you enroll in the Program of All-inclusive Care for the Elderly (PACE). Note: PACE is

not available in all states. If you would like to know if PACE is available in your state, please

contact Customer Service at the numbers located on the back of your member ID card.

When are Special Enrollment Periods? The enrollment periods vary depending on

your situation.

What can you do? To find out if you are eligible for a Special Enrollment Period, please call

Medicare at 1.800.MEDICARE (1.800.633.4227), 24 hours a day, 7 days a week. TTY users should

call 1.877.486.2048. If you are eligible to end your membership because of a special situation, you

can choose to change both your Medicare health coverage and prescription drug coverage.

Section 2.3 Where can you get more information about when you can end your membership?

If you have any questions or would like more information on when you can end your membership:

You can call your former employer or retiree group benefits administrator.


You can find the information in the Medicare & You 2017 handbook.



o Everyone with Medicare receives a copy of Medicare & You each fall. Those new to

Medicare receive it within a month after first signing up.

o You can also download a copy from the Medicare website (http://www.medicare.gov).

Or you can order a printed copy by calling Medicare at the numbers below.

You can contact Medicare at 1.800.MEDICARE (1.800.633.4227), 24 hours a day, 7 days

a week. TTY users should call 1.877.486.2048.

SECTION 3 How do you end your membership in this plan?

For information about disenrolling from this plan, contact your group benefits administrator. Your group

benefits administrator can best explain your options, the implications of leaving this plan and the process to

follow to disenroll.

SECTION 4 Until your membership ends, you must keep getting

your drugs through this plan

Section 4.1 Until your membership ends, you are still a member of this plan

If you leave Express Scripts Medicare, it may take time before your membership ends and your new

Medicare coverage goes into effect. (See Section 2 for information on when your new coverage begins.)

During this time, you should continue to get your prescription drugs through this plan.

In order to have coverage through this plan until your new coverage starts, you should

continue to use our network pharmacies to get your prescriptions filled until your

membership in this plan ends. Usually, your prescription drugs are only covered if they are filled

at a network pharmacy, including through our home delivery pharmacy service.

SECTION 5 Express Scripts Medicare must end your membership in certain situations

Section 5.1 When must we end your membership?

Express Scripts Medicare must end your membership in the plan if any of the following happen:

If you do not stay continuously enrolled in Medicare Part A or Part B (or both).

If you move out of our service area for more than 12 months.

o If you move or take a long trip, you need to call Customer Service (phone numbers are listed

on the back of your member ID card) to find out if the place you are moving or traveling to is

in this plan’s service area.

If you become incarcerated (go to prison).

If you are not a United States citizen or lawfully present in the United States.

If you lie about or withhold information about other insurance you have that provides

prescription drug coverage.



If you intentionally give us incorrect information when you are enrolling in this plan and that

information affects your eligibility for this plan. (We cannot make you leave this plan for this

reason unless we get permission from Medicare first.)

If you continuously behave in a way that is disruptive and makes it difficult for us to provide care for

you and other members of this plan. (We cannot make you leave this plan for this reason unless we

get permission from Medicare first.)

If you let someone else use your member ID card to get prescription drugs. (We cannot make you

leave this plan for this reason unless we get permission from Medicare first.)

o If we end your membership because of this reason, Medicare may have your case

investigated by the Inspector General.

If you do not pay any plan premiums you are responsible for according to your group’s premium

payment policy.

o The plan must notify you in writing that you have a grace period to pay the plan premium

before we end your membership. Contact your group benefits administrator for more

information about your plan premium and its grace periods for paying your plan premium.

If you are required to pay the extra Part D amount because of your income and you do not pay it,

Medicare will disenroll you from this plan and you will lose prescription drug coverage.

Where can you get more information?

If you have questions or would like more information on when we can end your membership, you can call

Customer Service (phone numbers are listed on the back of your member ID card).

Section 5.2 We cannot ask you to leave this plan for any reason related to your health

Express Scripts Medicare is not allowed to ask you to leave our plan for any reason related to your health.

What should you do if this happens?

If you feel that you are being asked to leave this plan because of a health-related reason, you should call

Medicare at 1.800.MEDICARE (1.800.633.4227). TTY users should call 1.877.486.2048. You may call

24 hours a day, 7 days a week.

Section 5.3 You have the right to make a complaint if we end your membership in this plan

If we end your membership in this plan, we must tell you our reasons in writing for ending your

membership. We must also explain how to file a grievance or how to make a complaint about our decision

to end your membership. You can also look in Chapter 7, Section 7 for information about how to make a

complaint.


Chapter 9: Legal notices 81

Chapter 9. Legal notices

SECTION 1 Notice about governing law

Many laws apply to this Evidence of Coverage and some additional provisions may apply because they are

required by law. This may affect your rights and responsibilities even if the laws are not included or

explained in this document. The principal law that applies to this document is Title XVIII of the

Social Security Act and the regulations created under the Social Security Act by the Centers for

Medicare & Medicaid Services, or CMS. In addition, other Federal laws may apply and, under certain

circumstances, the laws of the state you live in.

SECTION 2 Notice about nondiscrimination

We don’t discriminate based on race, ethnicity, national origin, color, religion, sex, gender, age, mental or

physical disability, health status, claims experience, medical history, genetic information, evidence of

insurability, or geographic location. All organizations that provide Medicare prescription drug plans, like our

plan, must obey Federal laws against discrimination, including Title VI of the Civil Rights Act of 1964, the

Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans with Disabilities Act,

Section 1557 of the Affordable Care Act, and all other laws that apply to organizations that get Federal

funding and any other laws and rules that apply for any other reason.

SECTION 3 Notice about Medicare Secondary Payer subrogation rights

We have the right and responsibility to collect for covered Medicare prescription drugs for which Medicare

is not the primary payer. According to CMS regulations at 42 CFR sections 422.108 and 423.462,

Express Scripts Medicare, as a Medicare prescription drug plan sponsor, will exercise the same rights of

recovery that the Secretary exercises under CMS regulations in subparts B through D of part 411 of

42 CFR, and the rules established in this section supersede any State laws.


Chapter 10: Definitions of important words 82

Chapter 10. Definitions of important words

2017 Formulary (List of Covered Drugs) or Drug List – A list of prescription drugs covered by the plan.

The drugs on this list are selected by the plan with the help of doctors and pharmacists. The list includes

both brand-name and generic drugs. This list contains the most commonly used drugs and does not include

all Part D drugs covered by this plan.

Appeal – An appeal is something you do if you disagree with our decision to deny a request for coverage of

prescription drugs or payment for drugs you already received. For example, you may ask for an appeal if we

don’t pay for a drug you think you should be able to receive. Chapter 7 explains appeals, including the

process involved in making an appeal.

Brand-name drug – A prescription drug that is manufactured and sold by the pharmaceutical company that

originally researched and developed the drug. Brand-name drugs have the same active-ingredient formula as

the generic version of the drug. However, generic drugs are manufactured and sold by other drug

manufacturers and are generally not available until after the patent on the brand-name drug has expired.

Catastrophic Coverage stage – The stage in the Part D drug benefit where you pay a low copayment or

coinsurance for your drugs after you or other qualified parties on your behalf have spent $4,950 on covered

drugs during the covered year.

Centers for Medicare & Medicaid Services (CMS) – The Federal agency that administers Medicare.

Chapter 2 explains how to contact CMS.

Coinsurance – An amount you may be required to pay as your share of the cost for prescription drugs after

you pay any deductibles (if they apply). Coinsurance is usually a percentage (for example, 20%).

Complaint – The formal name for “making a complaint” is “filing a grievance.” The complaint process is

used for certain types of problems only. This includes problems related to quality of care, waiting times and

the customer service you receive. See also “Grievance” in this list of definitions.

Copayment – An amount you may be required to pay as your share of the cost for a prescription drug. A

copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a

prescription drug.

Cost-sharing – Cost-sharing refers to amounts that a member has to pay when drugs are received. (This is

in addition to the plan’s monthly premium.) Cost-sharing includes any combination of the following three

types of payments: (1) any deductible amount a plan may impose before drugs are covered; (2) any fixed

copayment amount that a plan requires when a specific drug is received; or (3) any coinsurance amount, a

percentage of the total amount paid for a drug, that a plan requires when a specific drug is received. A “daily

cost-sharing rate” may apply when your doctor prescribes less than a full month’s supply of certain drugs

for you and you are required to pay a copayment.

Coverage determination – A decision about whether a drug prescribed for you is covered by the plan and

the amount, if any, you are required to pay for the prescription. In general, if you bring your prescription to a

pharmacy and the pharmacy tells you the medication isn’t covered under your plan, that isn’t a coverage

determination. You need to call or write to your plan to ask for a formal decision about the coverage.

Coverage determinations are called “coverage decisions” in this document. Chapter 7 explains how to ask

us for a coverage decision.

Covered drugs – The term we use to mean all of the prescription drugs covered by this plan.

Creditable prescription drug coverage – Prescription drug coverage (for example, from an employer or

retiree group) that is expected to pay, on average, at least as much as Medicare’s standard prescription drug



coverage. People who have this kind of coverage when they become eligible for Medicare can generally

keep that coverage without paying a penalty if they decide to enroll in Medicare prescription drug

coverage later.

Customer Service – A department within this plan responsible for answering your questions about your

membership, benefits and filing grievances. See the back of your member ID card for information about

how to contact Customer Service.

Daily cost-sharing rate – A “daily cost-sharing rate” may apply when your doctor prescribes less than a full

month’s supply of certain drugs for you and you are required to pay a copayment. A daily cost-sharing rate

is the copayment divided by the number of days in a month’s supply. Here is an example: If your copayment

for a one-month supply of a drug is $31 and a one-month’s supply in your plan is 31 days, then your “daily

cost-sharing rate” is $1 per day. This means you pay $1 for each day’s supply when you fill your

prescription.

Deductible – The amount you must pay for prescriptions before this plan begins to pay (if your plan has a

deductible).

Disenroll or Disenrollment – The process of ending your membership in this plan. Disenrollment may be

voluntary (your own choice) or involuntary (not your own choice).

Dispensing fee – A fee charged each time a covered drug is dispensed to pay for the cost of filling a

prescription. The dispensing fee covers costs such as the pharmacist’s time to prepare and package the

prescription.

Drug Tier (Cost-sharing Tier) – Each drug on our drug list is placed in a drug, or cost-sharing, tier – for

example, Generic Drugs tier. The amount you pay as a copayment or coinsurance depends, in part, on which

tier the drug is in. You can find more information about tiers in your Formulary (List of Covered Drugs).

Emergency – A medical emergency is when you, or any other prudent layperson with an average

knowledge of health and medicine, believe that you have medical symptoms that require immediate medical

attention to prevent loss of life, loss of a limb or loss of function of a limb. The medical symptoms may be

an illness, injury, severe pain or a medical condition that is quickly getting worse.

Evidence of Coverage (EOC) and Disclosure Information – This document, along with your eligibility

record and any other attachments, riders or other optional coverage selected, which explains your coverage,

what we must do, your rights and what you have to do as a member of this plan.

Exception – A type of coverage determination allowing you to request that a plan restriction or limit be

waived for certain drugs. Examples include: allowing a different dosage or quantity of a drug, allowing you

to use a drug without getting approval for it in advance or allowing you to try a drug prescribed by your

doctor that would normally require you to try a different drug first.

Extra Help – A Medicare program to help people with limited income and resources pay Medicare

prescription drug program costs, such as premiums, deductibles and coinsurance.

Generic drug – A prescription drug that is approved by the Food and Drug Administration (FDA) as

having the same active ingredient(s) as the brand-name drug. Generally, a generic drug works the same as a

brand-name drug and usually costs less.

Grievance – A type of complaint you make about us or one of our network pharmacies, including a

complaint concerning the quality of your care. This type of complaint does not involve coverage or payment

disputes.

Initial coverage limit – The maximum limit of coverage under the Initial Coverage stage.



Initial Coverage stage – This is the stage before your total drug costs, including amounts you have paid

and what your plan has paid on your behalf for the year, have reached $3,700.

Late enrollment penalty (LEP) – An amount that may be added to your monthly premium for Medicare

prescription drug coverage if you go without creditable coverage (coverage that is expected to pay, on

average, at least as much as standard Medicare prescription drug coverage) for a continuous period of

63 days or more. You pay this higher amount as long as you have a Medicare drug plan. There are some

exceptions. For example, if you receive Extra Help from Medicare to pay your prescription drug plan costs,

the late enrollment penalty rules do not apply to you. If you receive Extra Help, you do not pay an LEP.

Medicaid (or Medical Assistance) – A joint Federal and state program that helps with medical costs for

some people with low incomes and limited resources. Medicaid programs vary from state to state, but most

healthcare costs are covered if you qualify for both Medicare and Medicaid. See the Appendix for

information about how to contact Medicaid in your state.

Medically Accepted Indication – A use of a drug that is either approved by the Food and Drug

Administration (FDA) or supported by certain reference books. See Chapter 3, Section 3 for more

information about a medically accepted indication.

Medicare – The Federal health insurance program for people 65 years of age or older, some people under

age 65 with certain disabilities and people with End-Stage Renal Disease, also called ESRD (generally those

with permanent kidney failure who need dialysis or a kidney transplant). People with Medicare can get their

Medicare health coverage through Original Medicare, a Medicare Cost Plan or a Medicare Advantage Plan.

Medicare Advantage (MA) Plan – Sometimes called Medicare Part C. A plan offered by a private

company that contracts with Medicare to provide you with all your Medicare Part A and Part B benefits.

A Medicare Advantage Plan can be an HMO, PPO, a Private Fee-for-Service (PFFS) Plan or a Medicare

Medical Savings Account (MSA) Plan. If you are enrolled in a Medicare Advantage Plan, Medicare services

are covered through the plan and are not paid for under Original Medicare. In many cases, Medicare

Advantage Plans also offer Medicare Part D (prescription drug coverage). These plans are called Medicare

Advantage Plans with Prescription Drug Coverage (MA-PD). Everyone who has Medicare Part A and

Part B is eligible to join any Medicare health plan that is offered in their area, except people with ESRD

(unless certain exceptions apply).

Medicare Annual Enrollment Period – A set time each fall when members can change their health or

drug plans or switch to Original Medicare. The Medicare Annual Enrollment Period is from

October 15 until December 7 every year.

Medicare Cost Plan – A Medicare Cost Plan is a plan operated by a health maintenance organization

(HMO) or Competitive Medical Plan (CMP) in accordance with a cost-reimbursed contract under section

1876(h) of the Act.

Medicare Coverage Gap Discount Program – A program that provides discounts on most covered

Part D brand-name drugs to Part D enrollees who have reached the Coverage Gap stage or total drug spend

of $3,700 and who are not already receiving Extra Help. Discounts are based on agreements between the

Federal government and certain drug manufacturers. For this reason, most, but not all, brand-name drugs are

discounted.

Medicare health plan – A Medicare health plan is offered by a private company that contracts with

Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the plan. This term

includes all Medicare Advantage Plans, Medicare Cost Plans, Demonstration/Pilot Programs and Programs

of All-Inclusive Care for the Elderly (PACE).

Medicare prescription drug coverage (Medicare Part D) – Insurance to help pay for outpatient

prescription drugs, vaccines, biologicals and some supplies not covered by Medicare Part A or Part B.



“Medigap” (Medicare Supplement Insurance) policy – Medicare supplement insurance sold by private

insurance companies to fill “gaps” in Original Medicare. Medigap policies only work with Original

Medicare. (A Medicare Advantage Plan is not a Medigap policy.)

Member (member of this plan, or plan member) – A person with Medicare who is eligible to get covered

services, who has enrolled in this plan and whose enrollment has been confirmed by the Centers for

Medicare & Medicaid Services (CMS).

Network pharmacy – A network pharmacy is a pharmacy where members of this plan can get their

prescription drug benefits. We call them “network pharmacies” because they contract with this plan. In most

cases, your prescriptions are covered only if they are filled at one of our network pharmacies.

Original Medicare (“Traditional Medicare” or “Fee-for-Service” Medicare) – Original Medicare is offered

by the Federal government and is not a private health plan like Medicare Advantage Plans and prescription

drug plans. Under Original Medicare, Medicare services are covered by paying doctors, hospitals and other

healthcare providers payment amounts established by Congress. You can see any doctor, hospital or other

healthcare provider that accepts Medicare. You must pay the deductible. Medicare pays its share of the

Medicare-approved amount and you pay your share. Original Medicare has two parts — Part A (Hospital

Insurance) and Part B (Medical Insurance) — and is available everywhere in the United States.

Out-of-network pharmacy – A pharmacy that doesn’t have a contract with this plan to coordinate or

provide covered drugs to members of this plan. As explained in this Evidence of Coverage, most drugs you

get from out-of-network pharmacies are not covered by this plan unless certain conditions apply.

Out-of-pocket costs – See the definition for “cost-sharing” at the beginning of this chapter. A member’s

cost-sharing requirement to pay for a portion of drugs received is also referred to as the member’s

out-of-pocket cost requirement. Your out-of-pocket costs are what move you toward the Catastrophic

Coverage stage.

Part C – see Medicare Advantage (MA) Plan.

Part D – The voluntary Medicare Prescription Drug Benefit Program. (For ease of reference, we will refer

to the prescription drug benefit program as Part D.)

Part D drugs – Drugs that can be covered under Part D. Certain categories of drugs were specifically

excluded by Congress from being covered as Part D drugs. Please refer to your 2017 Formulary (List of

Covered Drugs) or Chapter 3 for more information on what drugs are covered by this plan.

Part D Income-Related Monthly Adjustment Amount (Part D-IRMAA) – If your income is above a

certain limit, you will pay an income-related monthly adjustment amount in addition to your plan premium.

For example, individuals with income greater than $85,000 and married couples with income greater than

$170,000 must pay a higher Medicare Part B (medical insurance) and Medicare prescription drug coverage

premium amount. This additional amount is called the Part D income-related monthly adjustment amount.

Less than 5% of people with Medicare are affected, so most people will not pay a higher premium.

Preferred cost-sharing – Preferred cost-sharing means lower cost-sharing for certain covered Part D drugs

at certain network pharmacies, if your plan has pharmacies that offer preferred cost-sharing.

Premium – The periodic payment to Medicare, an insurance company or a healthcare plan for health or

prescription drug coverage.

Prior authorization – A type of plan restriction requiring approval in advance to get certain drugs that may

or may not be on our formulary. Some drugs are covered only if your doctor or other network provider gets

“prior authorization” from us. Covered drugs that need prior authorization are marked in the formulary.



Quality Improvement Organization (QIO) – A group of practicing doctors and other healthcare experts

paid by the Federal government to check and improve the care given to Medicare patients. See the

Appendix for information about how to contact the QIO in your state.

Quantity limits – A type of plan restriction on certain drugs that is designed to limit the use of selected

drugs for quality, safety or utilization reasons. Limits may be on the amount of the drug that we cover

per prescription or for a defined period of time.

Service Area – A geographic area where a prescription drug plan accepts members if it limits membership

based on where people live. The plan may permanently disenroll you if you move out of the plan’s service

area.

Special Enrollment Period – A set time when members can change their health or drug plans or return to

Original Medicare. Situations in which you may be eligible for a Special Enrollment Period include: if you

move outside the plan’s service area, if you are getting “Extra Help” with your prescription drug costs, if

you move into a nursing home or if we violate our contract with you.

Standard cost-sharing– Standard cost-sharing is cost-sharing other than preferred cost-sharing offered at a

network pharmacy, if your plan has pharmacies that offer preferred cost-sharing.

Step Therapy – A type of plan restriction on certain drugs that requires you to first try another drug to treat

your medical condition before we will cover the drug your doctor may have initially prescribed.

Supplemental Security Income (SSI) – A monthly benefit paid by the Social Security Administration to

people with limited income and resources who are disabled, blind or age 65 and older. SSI benefits are not

the same as Social Security benefits.


Appendix: Important phone numbers and resources I

AIDS Drug Assistance Programs

TTY numbers require special telephone equipment and are only for people who have difficulties with

hearing or speaking.

Alabama Alabama AIDS Drug Assistance Program

Alabama Department of Public Health

HIV/AIDS Division, The RSA Tower 201 Monroe Street, Suite 1400

Montgomery, AL 36104

toll-free: 1.866.574.9964

Alaska State of Alaska

Department of Health & Social Services

Division of Public Health

Section of Epidemiology, HIV/STD Program 3601 C Street, Suite 540

Anchorage, AK 99503

local:

local:

1.907.269.8000

1.907.263.2050

American

Samoa

American Samoa Department of Health LBJ Tropical Medical Center

Pago Pago, AS 96799

local: 1.684.633.4071

Arizona Arizona Department of Health Services

150 N. 18th Avenue, Suite 110

Phoenix, AZ 85007

local:

toll-free:

1.602.364.3610

1.800.334.1540

Arkansas Arkansas Department of Health

HIV/STD/Hepatitis C section

ADAP Division 4815 W. Markham, Slot 33

Little Rock, AR 72205

local:

toll-free:

1.501.661.2408

1.888.499.6544

California Office of AIDS

California Department of Public Health MS 7700, P.O. Box 997426

Sacramento, CA 95899-7426

local: 1.916.449.5900

Colorado Colorado Department of Public Health & Environment

Care and Treatment Program

ADAP-3800

4300 Cherry Creek Drive South

Denver, CO 80246-1530

local: 1.303.692.2716

Connecticut Connecticut AIDS Drug Assistance Program

Department of Social Services

Medical Operations Unit # 4

55 Farmington Avenue

Hartford, CT 06105-3730

toll-free: 1.800.233.2503

Delaware Division of Public Health, HIV/AIDS Program

Thomas Collins Building

540 S. DuPont Highway

Dover, DE 19901

local: 1.302.744.1050

District of

Columbia

DC ADAP

DC Department of Health 899 North Capitol Street, NE, 4th Floor

Washington, DC 20002

local:

TTY:

1.202.671.4900

711


Appendix: Important phone numbers and resources II




Florida HIV/AIDS Section

AIDS Drug Assistance Program 4052 Bald Cypress Way, BIN A09

Tallahassee, FL 32399

toll-free:

TTY:

1.800.352.2437

1.888.503.7118

Georgia Georgia Department of Public Health

ADAP 2 Peachtree Street, NW, 15th Floor

Atlanta, GA 30303-3186

local: 1.404.657.2700

Guam Department of Public Health and Social Services

Bureau of Communicable Disease Control

STD/HIV Program, Room 156 123 Chalan Kareta

Mangilao, GU 96913

local: 1.671.735.7166

Hawaii Hawaii Department of Health

Harm Reduction Services Branch

HIV Medical Management Services 3627 Kilauea Avenue, Suite 306

Honolulu, HI 96816

local: 1.808.733.9360

Idaho Idaho Ryan White Part B Program

450 West State Street

P.O. Box 83720

Boise, ID 83720-0036

local: 1.208.334.5612

Illinois Illinois Department of Public Health

Illinois ADAP Office

525 W. Jefferson Street, 1st Floor

Springfield, IL 62761

local:

TTY:

1.217.782.4977

1.800.547.0466

Indiana Indiana State Department of Health

2 North Meridian Street

Indianapolis, IN 46204

toll-free: 1.866.588.4948

Iowa Iowa Department of Public Health

321 East 12th Street

Des Moines, IA 50319-0075

local: 1.515.281.0926

Kansas Kansas Department of Health & Environment

1000 South West Jackson, Suite 210

Topeka, KS 66612-1274

local: 1.785.296.6174

Kentucky Kentucky Department for Public Health

Cabinet for Health and Family Services

275 East Main Street

Frankfort, KY 40621

toll-free: 1.866.510.0005

Louisiana Louisiana Office of Public Health

1450 Poydras Street, Suite 2136

New Orleans, LA 70112

local:

1.504.568.7474


Appendix: Important phone numbers and resources III




Maine Maine Center For Disease Control and Prevention

ADAP

40 State House Station

Augusta, ME 04330-9758

local:

TTY:

1.207.287.3747

711

Maryland Maryland Department of Health and Mental Hygiene

Maryland AIDS Drug Assistance Program (MADAP)

201 West Preston St.

Baltimore, MD 21201-2399

local:

toll-free:

TTY:

1.410.767.6535

1.800.205.6308

1.800.735.2258

Massachusetts Community Research Initiative of New England/HDAP 38 Chauncy Street, Suite 500

Boston, MA 02111

local:

toll-free:

1.617.502.1700

1.800.228.2714

Michigan Michigan Drug Assistance Program

Michigan Department of Health and Human Services

Division of Health, Wellness and Disease Control

HIV Care Section

109 Michigan Avenue, 9th Floor

Lansing, MI 48913

toll-free: 1.888.826.6565

Minnesota HIV/AIDS Programs

Department of Human Services P.O. Box 64972

St. Paul, MN 55164-0972

local:

toll-free:

TTY:

1.651.431.2414

1.800.657.3761

1.800.627.3529

Mississippi Mississippi Department of Health

Office of STD/HIV

Care and Services Division

P.O. Box 1700

570 East Woodrow Wilson Drive

Jackson, MS 39215-1700

local:

toll-free:

1.601.362.4879

1.888.343.7373

Missouri Bureau of HIV, STD, and Hepatitis

Missouri Department of Health and Senior Services P.O. Box 570

Jefferson City, MO 65102-0570

local:

TTY:

1.573.751.6439

711

Montana Montana Dept. of Public Health and Human Services

P.O. Box 202951

Cogswell Bldg C-211

Helena, MT 59620-2951

local: 1.406.444.4744

Nebraska Nebraska Department of Health & Human Services

Nebraska Ryan White ADAP

301 Centennial Mall South

Lincoln, NE 68509

local:

toll-free:

1.402.559.4673

1.866.632.2437

Nevada Office of HIV/AIDS

Nevada Division of Public and Behavioral Health

4126 Technology Way, Suite 200

Carson City, NV 89706

local: 1.775.684.3499


Appendix: Important phone numbers and resources IV




New

Hampshire

New Hampshire Department of Health &

Human Services CARE Program

29 Hazen Drive

Concord, NH 03301-6504

local:

toll-free:

TTY:

1.603.271.4502

1.800.852.3345

extension 4502

1.800.735.2964

New Jersey New Jersey Department of Health

AIDS Drug Distribution Program (ADDP) P.O. Box 722

Trenton, NJ 08625-0722

toll-free: 1.877.613.4533

New Mexico New Mexico Department of Health

HIV Services Program 1190 St. Francis Drive, Suite 1200

Santa Fe, NM 87502

local: 1.505.827.2435

New York HIV Uninsured Care Programs – ADAP

New York State Department of Health Empire Station

P.O. Box 2052

Albany, NY 12220-0052

toll-free:

out-of-state:

TTY:

1.800.542.2437

(in-state only)

1.518.459.1641

1.518.459.0121

North Carolina Communicable Disease Branch

Epidemiology Section

Division of Public Health

N.C. Dept. of Health and Human Services

1902 Mail Service Center

Raleigh, NC 27699-1902

local:

toll-free:

1.919.733.3419

1.877.466.2232

(in-state only)

North Dakota North Dakota Department of Health

HIV/AIDS Program 2635 East Main Ave.

Bismarck, ND 58506-5520

local:

toll-free:

1.701.328.2378

1.800.472.2180

(in-state only)

Northern

Mariana

Islands

STD/HIV/AIDS Program P.O. Box 500409

Saipan, MP 96950

local: 1.670.664.4050

Ohio Ohio Department of Health

HIV Care Services Section

Ohio HIV Drug Assistance Program (OHDAP) 246 North High Street

Columbus, OH 43215

toll-free: 1.800.777.4775

Oklahoma HIV/STD Service

Oklahoma State Department of Health 1000 NE 10th

Oklahoma City, OK 73117-1299

local: 1.405.271.4636

Oregon CAREAssist Program P.O. Box 14450

Portland, OR 97293-0450

local:

toll-free:

TTY:

1.971.673.0144

1.800.805.2313

1.971.673.1222


Appendix: Important phone numbers and resources V




Pennsylvania Department of Health

Special Pharmaceutical Benefits Program P.O. Box 8808

Harrisburg, PA 17105-8808

toll-free: 1.800.922.9384

Puerto Rico Commonwealth of Puerto Rico Department of Health

Ryan White Part B AIDS Drug Assistance Program P.O. Box 70184

San Juan, PR 00936

local: 1.787.765.2929

Rhode Island Executive Office of Health and Human Services

Medicaid Division/HIV Provision of Care Hazard Building, Suite 60

74 West Road

Cranston, RI 02920

local: 1.401.462.3294

South Carolina South Carolina AIDS Drug Assistance Program Mills/Jarrett Building, 3rd Floor

Box 101106

Columbia, SC 29211

local:

toll-free:

1.803.898.0174

1.800.856.9954

South Dakota South Dakota Department of Health

Ryan White Part B CARE Program 615 East 4th Street

Pierre, SD 57501-1700

local:

toll-free:

1.605.773.3737

1.800.592.1861

Tennessee Tennessee HIV Drug Assistance Program (HDAP)

Tennessee Department of Health 710 James Robertson Parkway

Nashville, TN 37243

local:

toll-free:

1.615.741.7500

1.800.525.2437

Texas Texas Department of State Health Services

HIV Medication Program ATTN: MSJA – MC 1873

P.O. Box 149347

Austin, TX 78714-9347

local:

toll-free:

1.512.533.3000

1.800.255.1090

U.S. Virgin

Islands

United States Virgin Islands Department of Health

Communicable Diseases Division 1303 Hospital Ground

Charlotte Amalie

St. Thomas, VI 00802

local: 1.340.774.9000

extension 4728

Utah Utah Department of Health

Bureau of Epidemiology 288 North 1460 West, P.O. Box 142104

Salt Lake City, UT 84114-2104

local: 1.801.538.6191

Vermont Vermont Medication Assistance Program

Vermont Department of Health P.O. Box 70, Drawer 41 IDEPI

Burlington, VT 05402

local:

toll-free:

TTY:

1.802.951.4005

1.800.244.7639

711


Appendix: Important phone numbers and resources VI




Virginia Virginia Department of Health

Eligibility, 1st Floor

109 Governor Street, Room 326

P.O. Box 2448

Richmond, VA 23218

toll-free:

1.855.362.0658

Washington Early Intervention Program P.O. Box 47841

Olympia, WA 98501

local:

toll-free:

TTY:

1.360.236.3426

1.877.376.9316

(in-state only)

711

West Virginia WV Ryan White Part B State Direct Services P.O. Box 6360

Wheeling, WV 26003

local:

1.304.232.6822

Wisconsin Department of Health Services

Division of Public Health P.O. Box 2659

Madison, WI 53701-2659

toll-free:

local:

TTY:

1.800.991.5532

1.608.267.6875

1.888.701.1251

Wyoming Wyoming Department of Health

Communicable Disease Services Program 6101 Yellowstone Road, Suite 510

Cheyenne, WY 82002

local: 1.307.777.5856

State Health Insurance Assistance Programs (SHIPs)



Alabama State Health Insurance Assistance Program (SHIP)

Alabama Department of Senior Services 201 Monroe Street, Suite 350

Montgomery, AL 36104

toll-free:

local:

1.800.243.5463

1.334.242.5743

Alaska State Health Insurance Assistance Program (SHIP)

Alaska Medicare Information Office 400 Gambell Street

Anchorage, AK 99501

toll-free:

local:

TTY:

1.800.478.6065

(in-state only)

1.907.269.3680

1.800.770.8973

Arizona State Health Insurance Assistance Program (SHIP)

Arizona Department of Economic Security

DES Division of Aging and Adult Services 1789 West Jefferson Street, Site Code 950A

Phoenix, AZ 85007

toll-free:

local:

TTY:

1.800.432.4040

1.602.542.4446

1.602.542.6366

Arkansas Senior Health Insurance Information Program

Arkansas Insurance Department 1200 West Third Street

Little Rock, AR 72201-1904

toll-free:

local:

1.800.224.6330

1.501.371.2782

California State Health Insurance Assistance Program (SHIP)

California Health Insurance Counseling and

Advocacy Program (HICAP) 1300 National Drive, Suite 200


toll-free:

TTY:

1.800.434.0222

1.800.735.2929


Appendix: Important phone numbers and resources VII




Colorado Senior Health Insurance Assistance Program (SHIP)

Division of Insurance, Colorado Department of

Regulatory Agencies 1560 Broadway, Suite 850

Denver, CO 80202

toll-free:

TTY:

1.888.696.7213

1.303.894.7880

Connecticut CHOICES

Department of Aging

55 Farmington Ave, 12th Floor

Hartford, CT 06105-3730

toll-free:

local:

TTY:

1.800.994.9422

(in-state only)

1.860.424.5274

711

Delaware The Delaware Medicare Assistance Bureau (DMAB)

Delaware Department of Insurance

841 Silver Lake Boulevard

Dover, DE 19904-2465

toll-free:

local:

1.800.336.9500

1.302.674.7364

District of

Columbia

Health Insurance Counseling Project (HICP)

Jacob Burns Community Legal Clinics

The George Washington University Law School

650 20th Street, NW

Washington, D.C. 20052

local:

local:

1.202.994.6272

1.202.739.0668

Florida SHINE Program

Florida Department of Elder Affairs

4040 Esplanade Way, Suite 270

Tallahassee, FL 32399-7000

toll-free:

local:

TTY:

1.800.963.5337

1.850.414.2000

1.800.955.8770

Georgia GeorgiaCares

Georgia DHS Division of Aging Services

2 Peachtree Street, NW, 33rd Floor

Atlanta, GA 30303-3142

toll-free:

local:

TTY:

1.866.552.4464,

option #4

1.404.657.5258

Relay 711

Guam Division of Senior Citizens Guam 130 University Drive, Suite 8

University Castle Mall

Mangilao, GU 96913

local:

TTY:

1.671.735.7382

1.671.735.7415

Hawaii Sage PLUS Program/Hawaii SHIP

Executive Office on Aging

No. 1 Capitol District 250 South Hotel Street, Suite 406

Honolulu, HI 96813-2831

toll-free:

local:

TTY:

1.888.875.9229

1.808.586.7299

1.866.810.4379

Idaho Senior Health Insurance Benefits Advisors

(SHIBA) of Idaho

Department of Insurance

700 West State Street, 3rd Floor

P.O. Box 83720

Boise, ID 83720-0043

toll-free: 1.800.247.4422

Illinois Senior Health Insurance Program (SHIP)

Illinois Department on Aging

One Natural Resources Way, Suite 100

Springfield, IL 62702-1271

toll-free:

TTY:

1.800.252.8966

1.888.206.1327


Appendix: Important phone numbers and resources VIII




Indiana State Health Insurance Assistance Program (SHIP)

Indiana Department of Insurance 714 West 53rd Street

Anderson, IN 46013

toll-free:

TTY:

1.800.452.4800

1.866.846.0139

Iowa Senior Health Insurance Information Program (SHIIP) 601 Locust St., 4th Floor

Des Moines, IA 50309-3738

toll-free:

TTY:

1.800.351.4664

1.800.735.2942

(in-state only)

Kansas Senior Health Insurance Counseling

for Kansas (SHICK)

Kansas Department for Aging and Disability Services

New England Building

503 South Kansas Avenue

Topeka, KS 66603-3404

toll-free:

toll-free:

TTY:

1.800.860.5260

1.800.432.3535

1.800.766.3777

Kentucky State Health Insurance Assistance Program (SHIP)

Kentucky Cabinet for Health and Family Services

Department for Aging and Independent Living

Office of the Secretary 275 East Main Street, 3E-E

Frankfort, KY 40621

toll-free:

local:

TTY:

1.877.293.7447

option #2

1.502.564.6930

1.888.642.1137

Louisiana Senior Health Insurance Information Program (SHIIP)

Louisiana Department of Insurance P.O. Box 94214

Baton Rouge, LA 70804-9214

toll-free:

local:

1.800.259.5300

1.225.342.5301

Maine OADS Aging Services

Department of Health and Human Services

41 Anthony Avenue, Station 11

Augusta, ME 04333

toll-free:

local:

TTY:

1.800.262.2232

1.207.287.9200

711

Maryland Senior Health Insurance Assistance Program (SHIP)

Maryland Department of Aging 301 West Preston Street, Suite 1007

Baltimore, MD 21201

toll-free:

local:

out-of-state:

1.800.243.3425

(in-state only)

1.410.767.1100

1.844.627.5465

Massachusetts Serving Health Information Needs of Elders (SHINE)

Executive Office of Elder Affairs One Ashburton Place, Room 517

Boston, MA 02108-1618

toll-free:

local:

TTY:

1.800.243.4636

1.617.727.7750

1.800.872.0166

Michigan Michigan Medicare/Medicaid

Assistance Program (MMAP, Inc.) 6105 West St. Joseph Highway, Suite 204

Lansing, MI 48917

toll-free:

local:

1.800.803.7174

1.517.886.0899

Minnesota Minnesota SHIP/Senior LinkAge Line

Minnesota Board on Aging P.O. Box 64976

St. Paul, MN 55164-0976

toll-free:

TTY:

1.800.333.2433

1.800.627.3529


Appendix: Important phone numbers and resources IX




Mississippi State Health Insurance Assistance Program (SHIP)

Mississippi Department of Human Services

Division of Aging and Adult Services 750 North State Street

Jackson, MS 39202

toll-free:

local:

1.800.948.3090

1.601.359.4929

Missouri Missouri CLAIM 200 North Keene Street, Suite 101

Columbia, MO 65201

toll-free:

local:

1.800.390.3330

1.573.817.8320

Montana Montana State Health Insurance

Assistance Program (SHIP)

Senior and Long Term Care Division

2030 11th Avenue

Helena, MT 59601

toll-free:

local:

TTY:

1.800.551.3191

1.406.444.4077

1.800.253.4091

Nebraska Nebraska Senior Health Insurance

Information Program (SHIIP)

Nebraska Department of Insurance 941 O Street, Suite 400

Lincoln, NE 68508

toll-free:

local:

TTY:

1.800.234.7119

1.402.471.2841

1.800.833.7352

Nevada State Health Insurance Assistance Program (SHIP)

3416 Goni Road, Suite D-132


toll-free:

local:

1.800.307.4444

1.702.486.3478

New

Hampshire

ServiceLink Aging and Disability Resource Center

New Hampshire Department of Health and

Human Services

129 Pleasant Street

Concord, NH 03301-3857

toll-free:

TTY:

1.866.634.9412

1.800.735.2964

New Jersey State Health Insurance Assistance Program (SHIP)

New Jersey Department of Human Services

Division of Aging Services P.O. Box 715


toll-free:

toll-free:

1.800.792.8820

(in-state only)

1.877.222.3737

New Mexico Benefits Counseling Program

New Mexico Aging and Long-Term Services

Department

P.O. Box 27118

Santa Fe, NM 87502-7118

toll-free:

local:

TTY:

1.800.451.2901

1.505.476.4799

1.505.476.4937

New York Health Insurance Information Counseling and

Assistance Program (HIICAP)

New York State Office for the Aging

2 Empire State Plaza

Agency Building # 2, 4th Floor

Albany, NY 12223-1251

toll-free:

toll-free:

1.800.701.0501

1.800.342.9871


Appendix: Important phone numbers and resources X




North Carolina Seniors’ Health Insurance

Information Program (SHIIP)

North Carolina Department of Insurance

1201 Mail Service Center


toll-free:

local:

TTY:

1.855.408.1212

1.919.807.6900

1.800.735.2962

North Dakota State Health Insurance Counseling Program (SHIC)

North Dakota Insurance Department

600 East Boulevard Avenue


toll-free:

local:

TTY:

1.888.575.6611

1.701.328.2440

1.800.366.6888

Ohio Ohio Senior Health Insurance

Information Program (OSHIIP)

Ohio Department of Insurance 50 West Town Street, 3rd Floor, Suite 300

Columbus, OH 43215

toll-free:

local:

TTY:

1.800.686.1578

1.614.644.2658

1.614.644.3745

Oklahoma Senior Health Insurance Counseling Program (SHIP)

Oklahoma Insurance Department

5 Corporate Plaza

3625 NW 56th Street, Suite 100

Oklahoma City, OK 73112-4511

toll-free:

local:

1.800.763.2828

(in-state only)

1.405.521.6628

Oregon Senior Health Insurance Benefits Assistance (SHIBA)

350 Winter Street NE, Room 330

Salem, OR 97301

toll-free:

local:

TTY:

1.800.722.4134

1.503.947.7979

1.800.735.2900

Pennsylvania APPRISE

Commonwealth of Pennsylvania

Department of Aging 555 Walnut Street, 5th Floor


toll-free:

1.800.783.7067

Puerto Rico State Health Insurance Assistance Program (SHIP) P.O. Box 50063

San Juan, PR 00902

toll-free:

local:

1.800.981.7735

(San Juan)

1.787.721.6121

Rhode Island Senior Health Insurance Program (SHIP)

Rhode Island Department of Human Services

Division of Elderly Affairs 57 Howard Avenue

Louis Pasteur Bldg., 2nd Floor

Cranston, RI 02920

local:

TTY:

1.401.462.3000

1.401.462.0740

South Carolina Insurance Counseling Assistance and Referrals

for Elders (I-CARE)

Lieutenant Governor’s Office on Aging

1301 Gervais Street, Suite 350

Columbia, SC 29201

toll-free:

local:

1.800.868.9095

1.803.734.9900

South Dakota Senior Health Information and

Insurance Education (SHIINE)

South Dakota Department of Social Services

700 Governors Drive

Pierre, SD 57501

toll-free:

local:

1.800.536.8197

1.605.333.3314


Appendix: Important phone numbers and resources XI




Tennessee Tennessee State Health Insurance

Information Program (SHIP)

Tennessee Commission on Aging and Disability

Andrew Jackson Building

502 Deaderick Street, 9th Floor

Nashville, TN 37243-0860

toll-free:

local:

TTY:

1.877.801.0044

1.615.741.2056

1.800.848.0299

Texas Health Information Counseling and

Advocacy Program (HICAP)

Texas Department of Aging and

Disability Services (DADS)

P.O. Box 149030

Austin, TX 78714-9030

toll-free:

local:

TTY:

1.800.252.9240

1.512.438.3011

1.800.735.2989

U.S. Virgin

Islands

VI SHIP Office Schneider Regional Medical Center

9048 Sugar Estate

1st Floor


VI SHIP Office

Gov. Juan F. Luis Hospital and Medical Center

4007 Estate Diamond

1st Floor

St. Croix, VI 00820

local: 1.340.714.4354

(St. Thomas)

1.340.772.7368

(St. Croix)

Utah Senior Health Insurance Information Program (SHIIP)

Aging and Adult Services of Utah 195 North 1950 West

Salt Lake City, UT 84116

toll-free:

toll-free:

local:

1.877.424.4640

1.800.541.7735

1.801.538.3910

Vermont State Health Insurance Assistance Program (SHIP)

76 Pearl Street, Suite 201

Essex Junction, VT 05452

toll-free:

local:

1.800.642.5119

(in-state only)

1.802.865.0360

Virginia Virginia Insurance Counseling and Assistance

Program (VICAP)

Virginia Division for the Aging

1610 Forest Avenue, Suite 100

Henrico, VA 23229

toll-free:

local:

TTY:

1.800.552.3402

1.804.662.9333

Relay 711

Washington Statewide Health Insurance Benefits Advisors (SHIBA)

Office of the Insurance Commissioner P.O. Box 40255

Olympia, WA 98504-0255

toll-free:

TTY:

1.800.562.6900

1.360.586.0241

West Virginia West Virginia State Health Insurance

Assistance Program (WV SHIP)

West Virginia Bureau of Senior Services

1900 Kanawha Boulevard East

Charleston, WV 25305

toll-free:

local:

1.877.987.4463

1.304.558.3317


Appendix: Important phone numbers and resources XII




Wisconsin State Health Insurance Assistance Program (SHIP)

Department of Health Services

Board on Aging and Long Term Care 1 West Wilson Street

Madison, WI 53703

toll-free:

local:

TTY:

1.800.242.1060

1.608.266.1865

1.888.701.1251

Wyoming Wyoming State Health Insurance Information

Program (WSHIIP) 106 West Adams Avenue

Riverton, WY 82501

toll-free:

local:

1.800.856.4398

1.307.856.6880

State Medicaid Offices



Alabama Alabama Medicaid Agency P.O. Box 5624

Montgomery, AL 36103-5624

local:

toll-free:

1.334.242.5000

1.800.362.1504

Alaska Alaska Department of Health and Social Services 350 Main Street, Room 404

P.O. Box 110601

Juneau, AK 99811-0601

local:

TTY:

1.907.465.3030

1.907.586.4265

American

Samoa

American Samoa Medicaid State Agency

ASTCA Executive Building #304 P.O. Box 998383

Pago Pago, AS 96799

local: 1.684.699.4777

Arizona Arizona Health Care Cost Containment

System (AHCCCS) 801 East Jefferson Street, MD 4100

Phoenix, AZ 85034

local:

toll-free:

TTY:

1.602.417.4000

1.800.962.6690

1.602.417.4191

Arkansas Arkansas Division of Medical Services

Department of Human Services

Donaghey Plaza South

P.O. Box 1437, Slot S401

Little Rock, AR 72203-1437

local:

toll-free:

1.501.682.8233

1.800.482.8988

California Medi-Cal

Department of Health Care Services P.O. Box 997417, MS 4607


local: 1.916.552.9200

Colorado Department of Health Care Policy and Financing

1570 Grant Street

Denver, CO 80203-1818

toll-free:

TTY:

1.800.221.3943

711

Connecticut Husky Health Program

c/o Department of Social Services 55 Farmington Avenue

Hartford, CT 06105

toll-free:

TTY:

1.800.656.6684

1.800.410.1681


Appendix: Important phone numbers and resources XIII




Delaware Delaware Health and Social Services

Division of Medicaid and Medical Assistance 1901 North DuPont Highway, Lewis Building

New Castle, DE 19720

local:

toll-free:

1.302.255.9500

1.800.372.2022

District of

Columbia

DC Department of Health Care Finance

441 4th Street, NW, 900S

Washington, DC 20001

local:

TTY:

1.202.727.5355

711

Florida Florida Agency for Health Care Administration 2727 Mahan Drive

Tallahassee, FL 32308

toll-free:

TTY:

1.888.419.3456

1.800.955.8771

Georgia Georgia Department of Community Health 2 Peachtree Street Northwest

Atlanta, GA 30303

local:

toll-free:

1.404.656.4507

1.866.211.0950

Guam Medicaid/NIP Off-Island Referral Office

Bureau of Health Care Financing Administration Room 238

123 Chalan Kareta

Mangilao, GU 96913

local: 1.671.735.7224

or

1.671.735.7302

Hawaii Med-QUEST Division

Department of Human Services 801 Dillingham Boulevard, 3rd Floor

Honolulu, HI 96817

local:

toll-free:

1.808.524.3370

1.800.316.8005

Idaho Idaho Department of Health and Welfare P.O. Box 83720

Boise, ID 83720-0026

local:

TTY:

1.877.456.1233

1.800.377.1363

Illinois Illinois Department of Healthcare and Family Services 201 South Grand Avenue East

Springfield, IL 62763

local:

toll-free:

TTY:

1.217.782.1200

1.800.226.0768

1.877.204.1012

Indiana Family and Social Services Administration

Office of Medicaid Policy and Planning

402 West Washington Street

P.O. Box 7083

Indianapolis, IN 46204

local:

toll-free:

toll-free:

1.317.713.9627

1.800.889.9949

1.800.403.0864

Iowa Iowa Medicaid Enterprise

Department of Human Services

Member Services

P.O. Box 36510

Des Moines, IA 50315

local:

toll-free:

1.515.256.4606

1.800.338.8366

Kansas KanCare 900 S.W. Jackson, Suite 900N

Topeka, KS 66612-1220

toll-free:

TTY:

1.866.305.5147

1.800.766.3777


Appendix: Important phone numbers and resources XIV




Kentucky Department for Medicaid Services

Cabinet for Health and Family Services

Office of the Secretary

275 East Main Street

Frankfort, KY 40621

local:

toll-free:

1.502.564.4321

1.800.635.2570

Louisiana Department of Health and Hospitals P.O. Box 629

Baton Rouge, LA 70821-0629

toll-free: 1.888.342.6207

Maine Office of MaineCare Services 11 State House Station

Augusta, ME 04333-0011

local:

toll-free:

TTY:

1.207.287.2674

1.800.977.6740

Relay 711

Maryland Department of Health and Mental Hygiene

201 West Preston Street

Baltimore, MD 21201

local:

toll-free:

TTY:

1.410.767.5800

1.800.456.8900

1.800.735.2258

Massachusetts MassHealth Office of Medicaid 1 Ashburton Place, 11th Floor

Boston, MA 02108

toll-free:

TTY:

1.800.841.2900

1.800.497.4648

Michigan Michigan Department of Community Health Capitol View Building

201 Townsend Street

Lansing, MI 48913

local:

1.517.373.3740

Minnesota Department of Human Services

Health Care Eligibility and Access Division P.O. Box 64989

St. Paul, MN 55164-0989

local:

toll-free:

TTY:

1.651.431.2670

1.800.657.3739

1.800.627.3529

Mississippi Mississippi Division of Medicaid Sillers Building

550 High Street, Suite 1000

Jackson, MS 39201-1399

local:

toll-free:

1.601.359.6050

1.800.421.2408

Missouri The State of Missouri, MO HealthNet Division 615 Howerton Court

P.O. Box 6500


local:

toll-free:

TTY:

1.573.751.3425

1.800.392.2161

1.800.735.2966

Montana Department of Public Health and Human Services

Health Resources Division 1400 East Broadway Street, Cogswell Building

Helena, MT 59601-5231

local:

toll-free:

1.406.444.4540

1.800.362.8312

Nebraska Department of Health and Human Services

Access Nebraska P.O. Box 95026

Lincoln, NE 68509-5026

local:

toll-free:

TTY:

1.402.471.3121

1.855.632.7633

1.402.471.7256

Nevada Department of Health and Human Services

Division of Health Care Financing and Policy

1100 East William Street, Suite 101


local:

Las Vegas:

toll-free:

1.775.684.3600

1.702.668.4200

1.800.992.0900


Appendix: Important phone numbers and resources XV




New

Hampshire


Office of Medicaid Business and Policy 129 Pleasant Street

Concord, NH 03301

local:

toll-free:

TTY:

1.603.271.4344

1.800.852.3345

extension 4344

(in-state only)

1.800.735.2964

New Jersey Department of Human Services

Division of Medical Assistance and Health Services P.O. Box 712


toll-free:

TTY:

1.800.356.1561

(in-state only)

1.877.294.4356

New Mexico Human Services Department

Medical Assistance Division P.O. Box 2348

Santa Fe, NM 87504-2348

local:

toll-free:

1.505.827.3100

1.888.997.2583

New York New York State Department of Health Corning Tower

Empire State Plaza

Albany, NY 12237

toll-free: 1.800.541.2831

North Carolina Department of Health and Human Services

Division of Medical Assistance 2501 Mail Service Center


local:

toll-free:

1.919.855.4100

1.800.662.7030

North Dakota Department of Human Services

Medical Services Division 600 East Boulevard Avenue, Department 325


local:

toll-free:

TTY:

1.701.328.2321

1.800.755.26041

1.800.366.6888

Northern

Mariana

Islands

State Medicaid Agency Government Bldg. No. 1252

Capitol Hill Rd.

Caller Box 10007

Saipan, MP 96950

local: 1.670.664.4890

Ohio Department of Medicaid

50 West Town Street, Suite 400

Columbus, OH 43215

toll-free: 1.800.324.8680

Oklahoma Oklahoma Health Care Authority 2401 N.W. 23rd Street, Suite 1A

Oklahoma City, OK 73107

local:

toll-free:

TTY:

1.405.522.7171

1.800.987.7767

1.800.757.5979

Oregon Oregon Health Plan

Health Systems Division

500 Summer Street, NE

Salem, OR 97301-1079

local:

toll-free:

TTY:

1.503.945.5772

1.800.527.5772

711

Pennsylvania Department of Human Services

Office of Medical Assistance Programs P.O. Box 2675


toll-free:

TTY:

1.800.842.2020

1.800.451.5886


Appendix: Important phone numbers and resources XVI




Puerto Rico Department of Health P.O. Box 70184

San Juan, PR 00936-8184

local: 1.787.641.4224

Rhode Island Department of Human Services Louis Pasteur Building

600 New London Avenue

Cranston, RI 02920

local:

TTY:

1.401.462.5300

1.800.745.5555

South Carolina Department of Health and Human Services P.O. Box 8206

Columbia, SC 29202-8206

local:

toll-free:

1.803.898.2500

1.888.549.0820

South Dakota Department of Social Services 700 Governors Drive

Pierre, SD 57501

local:

toll-free:

1.605.773.4678

1.800.597.1603

Tennessee TennCare 310 Great Circle Road

Nashville, TN 37243

toll-free:

TTY:

1.855.259.0701

1.877.779.3103

Texas Texas Health and Human Services Commission Brown-Heatly Building

4900 North Lamar Boulevard, 4th Floor

Austin, TX 78751-2316

toll-free:

TTY:

1.800.252.8263

1.800.735.2989

U.S. Virgin

Islands

VI Medicaid Program

Department of Human Services Knud Hansen Complex

1303 Hospital Ground, Bldg. A


VI Medicaid Program

Department of Human Services 3011 Golden Rock, Christiansted

St. Croix, VI 00820

local: 1.340.715.6929

Utah Utah Department of Health

Division of Medicaid and Health Financing P.O. Box 143106

Salt Lake City, UT 84114-3106

local:

toll-free:

1.801.538.6155

1.800.662.9651

Vermont Department of Vermont Health Access

Agency of Human Services

312 Hurricane Lane, Suite 201

Williston, VT 05495

toll-free:

TTY:

1.800.250.8427

1.888.834.7898

Virginia Department of Medical Assistance Services 600 East Broad Street

Richmond, VA 23219

local:

toll-free:

TTY:

1.804.786.7933

1.855.242.8282

1.888.221.1590

Washington Department of Social and Health Services

Customer Service Center P.O. Box 11699

Tacoma, WA 98411-9905

toll-free:

TTY:

1.800.562.3022

711


Appendix: Important phone numbers and resources XVII




West Virginia Department of Health and Human Resources

Bureau for Medical Services 350 Capitol Street, Room 251

Charleston, WV 25301

local:

toll-free:

1.304.348.3365

1.877.716.1212

Wisconsin Department of Health Services

1 West Wilson Street

Madison, WI 53703

local:

toll-free:

TTY:

1.608.266.1865

1.800.362.3002

1.888.701.1251

Wyoming Division of Healthcare Financing, Medicaid 6101 Yellowstone Road, Suite 210

Cheyenne, WY 82002

local:

toll-free:

TTY:

1.307.777.7531

1.855.294.2127

1.855.329.5204




Colorado Bridging the Gap

Colorado AIDS Drug Assistance Program (ADAP)

Colorado Department of Public Health and

Environment

DCEED-STD-A3

4300 Cherry Creek Drive South

Denver, CO 80246-1530

local: 1.303.692.2716

Delaware Chronic Renal Disease Program (CRDP)

Milford State Service Center

11-13 Church Avenue

Milford, DE 19963

local:

Help Line:

1.302.424.7180

1.800.464.4357

Delaware Delaware Prescription Assistance Program (DPAP)

EDS DPAP P.O. Box 950

New Castle, DE 19720-0950

toll-free: 1.800.996.9969

extension 2

Idaho Idaho AIDS Drug Assistance Program (IDAGAP)

Department of Health and Welfare

Idaho Ryan White Part B Program

450 West State Street, 4th Floor

P.O. Box 83720

Boise, ID 83720-0036

local:

toll-free:

alternate

main line:

1.208.334.6657

1.800.926.2588

1.208.334.6527

Indiana HoosierRx P.O. Box 6224

Indianapolis, IN 46206-6224

local:

toll-free:

1.317.234.1381

1.866.267.4679

Maine Low Cost Drugs for the Elderly and

Disabled Program (DEL)

Office of Aging & Disability Services

Maine Department of Health and Human Services

11 State House Station

41 Anthony Avenue

Augusta, ME 04333

local:

toll-free:

TTY:

1.207.287.9200

1.800.262.2232

Relay 711


Appendix: Important phone numbers and resources XVIII




Maryland Maryland Senior Prescription Drug

Assistance Program (SPDAP)

c/o Pool Administrators

628 Hebron Avenue, Suite 100

Glastonbury, CT 06033

toll-free:

TTY:

1.800.551.5995

1.800.877.5156

Maryland Maryland Kidney Disease Program 201 West Preston Street, Room SS-3

Baltimore, MD 21201

local: 1.410.767.5000

Maryland Primary Adult Care Program (PAC) P.O. Box 386

Baltimore, MD 21203-0386

toll-free: 1.800.226.2142

Massachusetts Prescription Advantage P.O. Box 15153

Worcester, MA 01615-0153

toll-free:

TTY:

1.800.243.4636

extension 2

1.877.610.0241

Missouri Missouri Rx Plan

P.O. Box 6500


toll-free: 1.800.375.1406

Montana Big Sky Rx Program P.O. Box 202915

Helena, MT 59620-2915

toll-free:

out-of-state

& Helena:

1.866.369.1233

1.406.444.1233

Montana Mental Health Services Plan (MHSP)

Addictive and Mental Disorders Division 555 Fuller Avenue, P.O. Box 202905

Helena, MT 59620-2905

local:

toll-free:

1.406.444.3964

1.888.866.0328

Montana AIDS Drug Assistance Program (ADAP)

Department of Public Health and Human Services

HIV/STD Section

P.O. Box 202951, Cogswell Building C-211

Helena, MT 59620-2951

local: 1.406.444.4744

Nevada Nevada Senior Rx/Disability Rx


Aging and Disability Services Division

3416 Goni Road, Building D, Suite D-132


local:

toll-free:

1.775.687.4210

(Reno,

Carson City,

Gardnerville)

1.866.303.6323

New Jersey New Jersey Department of Human Services

Pharmaceutical Assistance to the Aged and

Disabled (PAAD)

Lifeline and Special Benefit Programs

Senior Gold Prescription Discount Program

(Senior Gold)

P.O. Box 715


toll-free: 1.800.792.9745

New York Elderly Pharmaceutical Insurance Coverage (EPIC) P.O. Box 15018

Albany, NY 12212-5018

toll-free:

TTY:

1.800.332.3742

1.800.290.9138


Appendix: Important phone numbers and resources XIX




North Carolina North Carolina HIV SPAP 1902 Mail Service Center


local:

toll-free:

1.919.733.9161

1.877.466.2232

(in-state only)

Pennsylvania The Chronic Renal Disease Program

Pennsylvania Department of Health

Division of Child and Adult Health Services

625 Forster Street, 7th Floor, East Wing


toll-free:

toll-free:

1.877.724.3258

1.800.225.7223

Pennsylvania PACE/PACENET Program

Pennsylvania Department of Aging

Bureau of Pharmaceutical Assistance

555 Walnut Street, 5th Floor


local:

toll-free:

1.717.787.7313

1.800.225.7223

Pennsylvania Special Pharmaceutical Benefits Program – HIV/AIDS P.O. Box 8808


toll-free: 1.800.922.9384

Rhode Island Rhode Island Pharmaceutical Assistance

to the Elderly (RIPAE)

Attention: RIPAE

Rhode Island Department of Human Services

Division of Elderly Affairs 74 West Road, Hazard Building, 2nd Floor

Cranston, RI 02920

local:

TTY:

1.401.462.3000

1.401.462.0740

Texas Kidney Health Care Program (KHC)

Department of State Health Services, MC 1938 P.O. Box 149347

Austin, TX 78714-9347

local:

toll-free:

1.512.458.7150

1.800.222.3986

Texas Texas HIV State Pharmaceutical Assistance

Program (SPAP)

Department of State Health Services

HIV/STD Program P.O. Box 149347, MC 1873

Austin, TX 78714

toll-free: 1.800.255.1090

option #4

U.S. Virgin

Islands

Department of Human Resources

Knud Hansen Complex

1303 Hospital Ground, Bldg. A


Department of Human Resources

3011 Golden Rock, Christiansted

St. Croix, VI 00820

local: 1.340.774.0930

(St. Thomas)

1.340.773.2323

(St. Croix)

1.340.776.6334

(St. John)

Vermont VPharm/Healthy Vermonters 312 Hurricane Lane, Suite 201

Williston, VT 05495

local:

toll-free:

TTY:

1.802.879.5900

1.800.250.8427

1.888.834.7898


Appendix: Important phone numbers and resources XX




Virginia Virginia AIDS Drug Assistance Program (ADAP)

and Virginia HIV SPAP, Patient Services Incorporated P.O. Box 5930

Midlothian, VA 23112

toll-free: 1.800.366.7741

Washington Washington State Health Insurance Pool

P.O. Box 1090

Great Bend, KS 67530

toll-free: 1.800.877.5187

Wisconsin Wisconsin Chronic Disease Program

(Chronic Renal Disease, Cystic Fibrosis,

and Hemophilia Home Care Programs)

Attn: Eligibility Unit

P.O. Box 6410


toll-free: 1.800.362.3002

Wisconsin Wisconsin SeniorCare P.O. Box 6710


toll-free: 1.800.657.2038

Quality Improvement Organizations



Area 1:

CT, ME, MA, NH, NJ,

NY, PA, PR, RI, VI, VT

Livanta

BFCC-QIO Program

9090 Junction Drive, Suite 10

Annapolis Junction, MD 20701

toll-free:

TTY:

Appeals Fax:

Fax for all other

reviews:

1.866.815.5440

1.866.868.2289

1.855.236.2423

1.844.420.6671

Area 2:

DC, DE, FL, GA, MD,

NC, SC, VA, WV

KEPRO

5201 W. Kennedy Blvd., Suite 900

Tampa, FL 33609

toll free:

TTY:

Fax:

1.844.455.8708

1.855.843.4776

1.844.834.7129

Area 3:

AL, AR, CO, KY, LA,

MS, MT, ND, NM, OK,

SD, TN, TX, UT, WY

KEPRO

5700 Lombardo Center Drive

Suite 100

Seven Hills, OH 44131

toll free:

TTY:

Fax:

1.844.430.9504

1.855.843.4776

1.844.878.7921

Area 4:

IA, IL, IN, KS, MI,

MN, MO, NE, OH, WI

KEPRO

5201 W. Kennedy Blvd., Suite 900

Tampa, FL 33609

toll free:

TTY:

Fax:

1.855.408.8557

1.855.843.4776

1.844.834.7130

Area 5:

AK, AS, AZ, CA, GU, HI,

ID, MP, NV, OR, WA

Livanta

BFCC-QIO Program

9090 Junction Drive, Suite 10

Annapolis Junction, MD 20701

toll free:

TTY:

Appeals Fax:

Fax for all other

reviews:

1.877.588.1123

1.855.887.6668

1.844.834.7130

1.855.694.2929

1.844.420.6672


Appendix: Important phone numbers and resources XXI

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Appendix: Important phone numbers and resources XXII

© 2016 Express Scripts Holding Company. All Rights Reserved. Express Scripts and “E” Logo are

trademarks of Express Scripts Holding Company and/or its subsidiaries. Other trademarks are the

property of their respective owners.

E00SOS7A

(continued)

KEY[INJ] - Injectable DrugBrand-name drugs are listedin CAPITAL letters.

Generic drugs are listed inlower case letters.

Not all compoundedmedications are covered by the plan.

AABILIFY MAINTENA [INJ]ABSORICAACANYAacetaminophen/codeineACTEMRA [INJ]ACTHAR H.P. [INJ]acyclovirADCIRCAADEMPASADVAIR DISKUSADVAIR HFAAFSTYLA [INJ]AKYNZEOalbuterol nebulizationsolution

alendronateallopurinolALPHAGAN P 0.1%alprazolamALREXamiodaroneAMITIZAamitriptylineamlodipineamlodipine/benazeprilamlodipine/valsartanamoxicillinamoxicillin/potassiumclavulanate

AMPYRAanastrozoleANDRODERMANDROGEL 1.62%ANORO ELLIPTAapriAPRISOARCAPTA NEOHALERaripiprazoleARISTADA [INJ]ARMONAIR RESPICLICKARNUITY ELLIPTAASMANEX HFAASMANEX TWISTHALERatenololatenolol/chlorthalidoneatorvastatinAVONEX [INJ]

AZASITEazelastine nasal sprayazithromycin

BbaclofenbenazeprilbenzonatateBEPREVEBETASERON [INJ]BETHKISBEVESPI AEROSPHEREbisoprolol/hctzblisovi feBREO ELLIPTABRILINTABRISDELLEbudesonide nebulizationsuspension

bupropionbupropion ext-releasebuspironebutalbital/acetaminophen/caffeine

BYDUREON [INJ]BYETTA [INJ]BYSTOLICBYVALSON

CCANASACARACcarbidopa/levodopacarvedilolcefdinircefuroxime axetilcelecoxibcephalexinCETROTIDE [INJ]chlorhexidine gluconatechlorthalidoneCIALISCIPRODEXciprofloxacincitalopramclarithromycinclindamycin hclclindamycin phosphateclindamycin phosphate/benzoyl peroxide

clobetasol propionateclomiphene citrateclonazepamclonidineclopidogrelclotrimazole/betamethasonedipropionate

COLCRYSCOMBIGANCOMBIPATCHCOMBIVENT RESPIMATCOPAXONE 40 MG [INJ]COREG CRCORLANORCOSENTYX [INJ]CREONCRINONEcyanocobalamin [INJ]cyclobenzaprine

DDALIRESPDAYTRANAdesloratadinedesonidedesvenlafaxine succinate erdexamethasonedexmethylphenidate ext-release

dextroamphetamine/amphetamine

dextroamphetamine/amphetamine ext-release

diazepamdiclofenac sodium delayed-release

dicyclominedigoxindiltiazem ext-releasediphenoxylate/atropinedivalproex delayed-releasedivalproex ext-releaseDIVIGELdonepezildoxazosindoxycycline hyclatedoxycycline monohydrateDUAVEEDULERAduloxetine delayed-releaseDUPIXENT [INJ]DYMISTA

EEDARBIEDARBYCLORELIDELELIQUISEMVERMenalaprilENBREL [INJ]enoxaparin [INJ]ENSTILARENTRESTO

EPCLUSAEPIDUO, EPIDUO FORTEEPINEPHRINE AUTO-INJECTOR(by Mylan) [INJ]

EPIPEN, EPIPEN JR [INJ]ergocalciferolerythromycin eye ointmentescitalopramesomeprazole magnesiumdelayed-release

ESTRACE CREAMestradiolestradiol patchesestradiol/norethindroneacetate

ESTRINGeszopicloneEUFLEXXA [INJ]EVEKEOEXTAVIA [INJ]ezetimibe

FfamotidineFARXIGAfenofibratefenofibrate micronizedfenofibric acid delayed-release

fentanyl patchesFETZIMAFINACEAfinasterideFLECTORFLOVENT DISKUSFLOVENT HFAfluconazolefluocinonidefluoxetinefluticasone nasal sprayFLUTICASONE/SALMETEROLfolic acidFRAGMIN [INJ]furosemideFYCOMPA

GgabapentinGELNIQUEgemfibrozilGENOTROPIN [INJ]GILENYAGILOTRIFglimepirideglipizideglipizide ext-releaseGLUCAGEN [INJ]

GLUCAGON [INJ]glyburideGLYXAMBIGONAL-F, GONAL-F RFF,GONAL-F RFF REDI-JECT [INJ]

GRALISEGRANIX [INJ]GRASTEKguanfacine ext-release

HHARVONIHELIXATE FS [INJ]HUMALOG [INJ]HUMATROPE [INJ]HUMIRA [INJ]HUMULIN [INJ]hydralazinehydrochlorothiazidehydrocodone/acetaminophenhydrocodone/chlorpheniramine polistirexext-release

hydrocortisone topicalhydromorphonehydroxychloroquinehydroxyzine hclhydroxyzine pamoateHYSINGLA ER

IibandronateibuprofenILEVROINCRUSE ELLIPTAindomethacinINLYTAINVOKAMETINVOKAMET XRINVOKANAirbesartanIRESSAisosorbide mononitrate ext-release

JJANUMET, JANUMET XRJANUVIAJARDIANCEJENTADUETOJENTADUETO XRjunel fe

The following is a list of the most commonly prescribed drugs. It represents anabbreviated version of the drug list (formulary) that is at the core of your prescriptionplan. The list is not all-inclusive and does not guarantee coverage. In addition tousing this list, you are encouraged to ask your doctor to prescribe generic drugswhenever appropriate.

PLEASE NOTE: Brand-name drugs may move to nonformulary status if a genericversion becomes available during the year. Not all the drugs listed are covered byall prescription plans; check your benefit materials for the specific drugs coveredand the copayments for your prescription plan. For specific questions about yourcoverage, please call the phone number printed on your member ID card.

THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2018 THROUGH DECEMBER 31, 2018. THIS LIST IS SUBJECT TO CHANGE.You can find more information at express-scripts.com.

© 2017 Express Scripts Holding CompanyAll Rights Reserved

NP-APRMT6542ANP-18 (09/15/17)

Go to express-scripts.com/2018drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary.

2018 Express ScriptsNational Preferred FormularyFor State of New Hampshire

http://express-scripts.com/2018drugs

http://express-scripts.com

K

ketoconazole topicalketorolacKITABIS PAKKOGENATE FS [INJ]KOVALTRY [INJ]KYLEENA

Llabetalollamotriginelansoprazole delayed-releaseLANTUS [INJ]latanoprost eye solutionLATUDALETAIRISLEVEMIR [INJ]levetiracetamlevocetirizinelevofloxacinlevothyroxine sodiumlidocaine patchesLINZESSliothyronineLIPOFENlisinoprillisinopril/hctzLIVALOLO LOESTRIN FElorazepamlosartanlosartan/hctzLOTEMAXlovastatinLUMIGANLYRICA

MMAKENA [INJ]MAVYRETmeclizinemedroxyprogesteronemeloxicamMEPHYTONMESTINON SYRUPmetaxalonemetforminmetformin ext-releasemethimazolemethocarbamolmethotrexatemethylphenidatemethylphenidate ext-releasemethylprednisolonemetoclopramide hclmetoprolol succinate ext-release

metoprolol tartratemetronidazolemetronidazole topicalmetronidazole vaginal gelmicrogestin feMINIVELLEminocyclineMIRENAmirtazapine

MIRVASOMITIGAREmoderibamometasonemononessaMONOVISC [INJ]montelukastmorphine sulfate ext-releaseMOVANTIKMOXEZAmultivitamins/fluoridemupirocinMUSEMYDAYISMYRBETRIQ

NnabumetoneNAMENDA XRNAMZARICnaproxen, naproxen sodiumNARCAN NASAL SPRAYNASCOBALNATAZIAneomycin/polymyxin/hydrocortisone ear drops

NEXIUM PACKETSniacin ext-releasenifedipine ext-releasenitrofurantoin macrocrystalNORDITROPIN [INJ]nortriptylineNOVOEIGHT [INJ]NUCYNTA, NUCYNTA ERNUEDEXTANUVARINGnystatin oral suspensionnystatin topical

Oofloxacinolanzapineolmesartanolmesartan/hctzolopatadineomega-3 acid ethyl estersomeprazole delayed-releaseondansetronondansetron orallydisintegrating tablets

ONETOUCH KITS/METERS;ULTRA 2, ULTRAMINI,VERIO, VERIO FLEX, VERIO IQ, VERIO SYNC

ONETOUCH TEST STRIPS;ULTRA, VERIO

ONEXTONOPSUMITORACEAORTHOVISC [INJ]OTEZLAOTOVELOTREXUP [INJ]oxcarbazepineoxybutynin ext-releaseoxycodoneoxycodone/acetaminophen

OXYCONTIN

Ppantoprazole delayed-releaseparoxetinePAZEOpenicillin v potassiumPENTASAPERFOROMISTPHOSLYRAPICATOpioglitazonePLEGRIDY [INJ]polymyxin/trimethoprim eye solution

potassium chloride ext-release

PRALUENT [INJ]pramipexolepravastatinprednisolone acetate eye suspension

prednisolone sodiumphosphate

prednisonePREMARIN CREAMPREMARIN TABSPREMPHASEPREMPROPREPOPIKPROAIR HFAPROAIR RESPICLICKPROCRIT [INJ]progesterone micronizedPROLENSApromethazinepromethazine/dextromethorphan

propranololpropranolol ext-releasePULMICORT FLEXHALERPYLERA

QQNASLQUDEXY XRquetiapineQUILLICHEW ERQUILLIVANT XRquinaprilQVAR

Rrabeprazole delayed-releaseRAGWITEKraloxifeneramiprilRANEXAranitidineRAPAFLORASUVO [INJ]REBIF [INJ]RECTIVRELISTOR [INJ]REMICADE [INJ]RENVELA TABLETS

REPATHA [INJ]RESTASISrisperidonerizatriptanropinirolerosuvastatin

SSAFYRALSANCUSOSAVELLASEREVENT DISKUSsertralineSIMPONI 100 MG (forulcerative colitis only) [INJ]

simvastatinSKYLASOLIQUA [INJ]SOLODYNSOMATULINE DEPOT [INJ]SOOLANTRASPIRIVA HANDIHALERSPIRIVA RESPIMATspironolactonesprintecSPRYCELSTELARA SC [INJ]STIOLTO RESPIMATSTRENSIQ [INJ]STRIVERDI RESPIMATSUBOXONE SL FILMsulfamethoxazole/trimethoprim

sumatriptanSUPREPSYMBICORTSYMLINPEN [INJ]SYNJARDY, SYNJARDY XR

TTACLONEX SUSPENSIONtamoxifentamsulosin ext-releaseTARCEVATAYTULLATAZORAC GELTAZORAC 0.05% CREAMTECFIDERATECHNIVIETEKTURNA, TEKTURNA HCTtemazepamterazosinterconazole vaginaltestosterone cypionate [INJ]timolol maleate eye solutiontizanidineTOBI PODHALERTOBRADEX OINTMENTTOBRADEX STtobramycin eye solutiontobramycin/dexamethasoneeye suspension

topiramateTOUJEO SOLOSTAR [INJ]TOVIAZTRACLEERTRADJENTA

tramadolTRAVATAN ZtrazodoneTRESIBA [INJ]triamcinolone topicaltriamterene/hctztrinessatri-sprintecTRULICITY [INJ]TUDORZA PRESSAIRTYMLOS [INJ]

UUCERIS TABLETSULORICUPTRAVI

Vvalacyclovirvalsartanvalsartan/hctzVARUBIVASCEPAVELPHOROVELTASSAvenlafaxinevenlafaxine ext-releaseVENTOLIN HFAverapamil ext-releaseVESICAREVIAGRAVIBERZIVIEKIRA PAKVIEKIRA XRVIIBRYDVIMPATVIOKACEVOSEVIVYVANSE

WwarfarinWELCHOL

XXARELTOXELJANZ, XELJANZ XRXIFAXANXIGDUO XRXIIDRA XTANDIXULTOPHY [INJ]

ZZARXIO [INJ]ZENPEPzolpidemzolpidem ext-releaseZOMIG NASALZONTIVITYZOVIRAX CREAMZUBSOLVZYLETZYTIGA

THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2018 THROUGH DECEMBER 31, 2018. THIS LIST IS SUBJECT TO CHANGE.You can find more information at express-scripts.com.


NP-APRMT6542ANP-18 (09/15/17)

Please note that product placement for the Treatment for Inflammatory Conditions is under consideration and changes may occur based upon changes in market dynamics and new product launches.

Go to express-scripts.com/2018drugs for a full list of formulary exclusions with their covered alternatives or log on to compare drug prices. Costs for covered alternatives may vary.

http://express-scripts.com/2018drugs


2017 Preferred Drug List ExclusionsThe excluded medications shown below are not covered on the Express Scripts drug list. In most cases, if you fill a prescription for one of these drugs, you will pay the full retail price.

Take action to avoid paying full price. If you’re currently using one of the excluded medications, please ask yourdoctor to consider writing you a new prescription for one of the following preferred alternatives.

Drug Class Excluded Medications Preferred Alternatives

AUTONOMIC & CENTRALNERVOUS SYSTEMNarcotic Antagonists

Evzio naloxone syringe, Narcan nasal spray

Transmucosal Fentanyl Analgesics Abstral, Fentora, Subsys fentanyl citrate lozenges, Lazanda

DERMATOLOGICALOral Agents For Rosacea

Doxycycline 40 MG Capsules Oracea

Topical Acne/Antibiotic Combinations Veltinclindamycin/benzoyl peroxide, clindamycin/tretinoin, Acanya, Onexton

Topical Agents for Actinic Keratosis Fluorouracil 0.5% Cream, Zyclaradiclofenac gel, fluorouracil 5% cream, fluorouracil 2% solution, imiquimod 5% cream, Carac, Picato

DIABETESBiguanides

Glumetza metformin extended-release

Blood Glucose Meters & Test Strips

Abbott (FreeStyle, Precision), ADV MED TECH (TRUEtest, TRUEtrack), Advocate, Bayer (Breeze, Contour), Omnis Health (Embrace, Victory), Roche (Accu-Chek), UniStrip

LifeScan (OneTouch)

Dipeptidyl Peptidase-4 Inhibitors& Combinations

Alogliptin, Nesina, Onglyza Januvia, Tradjenta

Alogliptin/Metformin, Kazano, Kombiglyze XRJanumet, Janumet XR, Jentadueto, Jentadueto XR

Glucagon-Like Peptide-1 Agonists Tanzeum, Victoza Bydureon, Byetta, Trulicity

InsulinsNote: The Basal Insulins category may be reassessed later this year to reflect anticipated product launches.

Novolin Humulin

Apidra, NovoLog Humalog

EAR/NOSENasal Steroids

Beconase AQ, Omnaris, Veramyst, Zetonnabudesonide, flunisolide, fluticasone,mometasone, Qnasl

Otic Fluoroquinolone Antibiotics Cetraxalciprofloxacin ear solution, ofloxacin ear solution, Ciprodex

ENDOCRINE (OTHER)Growth Hormones

Nutropin AQ, Omnitrope, Saizen, Zomacton Genotropin, Humatrope, Norditropin

Topical Estrogen Gels Estrogel Divigel

Topical Testosterone ProductsFortesta, Natesto, Testim, Testosterone Gel, Vogelxo

AndroGel 1.62%, Axiron

GASTROINTESTINALAnti-Inflammatory/Anti-Ulcer Agents

Duexis ibuprofen PLUS famotidine

Vimovoomeprazole delayed-release PLUS naproxen sodium

Inflammatory Bowel Agents Asacol HD, Delzicol, Dipentumbalsalazide disodium, sulfasalazine, Apriso, Lialda, Pentasa

Pancreatic Enzymes Pancreaze, Pertzye, Ultresa Creon, Zenpep

HEMATOLOGICALErythropoiesis-Stimulating Agents

Aranesp, Epogen, Mircera Procrit

Continued


Additional covered alternatives may be available. Costs for covered alternatives may vary. Log on to Express-Scripts.com/covered to compare drug prices. Other prescription benefit considerations may apply.

Express Scripts manages your prescription benefit for your employer, plan sponsor or health plan.These changes apply to most Express Scripts national drug lists; does not apply to Medicare plans.

© 2017 Express Scripts. All Rights Reserved. Express Scripts and “E” Logo are trademarks of Express Scripts and/or its subsidiaries. Other trademarks are the property of their respective owners. DL44109Q-SD-17 204612 (07/31/2016)

Excluded Medications/Products at a Glance

Abbott (FreeStyle, Precision)AbstralAcuvailADV MED TECH (TRUEtest, TRUEtrack)

AdvocateAlogliptinAlogliptin/MetforminAlvescoApidraAranespAsacol HDBayer (Breeze, Contour)Beconase AQBravelleCetraxalCimziaColchicine

DaklinzaDelzicolDipentumDoxycycline 40 MG CapsulesDuexisEndometrinEpogenEstrogelEvzioFentoraFluorouracil 0.5% CreamFollistim AQFortestaGanirelix AcetateGel-OneGenvisc 850GlumetzaHyalgan

HymovisIstalolKazanoKineret (Exclude for RA)Kombiglyze XRLevitraMirceraNatestoNesinaNovolinNovoLogNutropin AQOlysioOmnarisOmnis Health (Embrace, Victory)

OmnitropeOnglyza

OrenciaPancreazePertzyeProventil HFAQsymiaribasphere ribapakRibaTabRoche (Accu-Chek)SaizenSimponi 50 MGSovaldiStaxynStendraSubsysSupartzSupartz FXSynviscSynvisc-One

TaltzTanzeumTestimTestosterone GelUltresaUniStripVeltinVeramystVictozaVimovoVogelxoXopenex HFAZepatierZetonnaZioptanZomactonZyclara

* Excluded medications may be covered for selected genotypes with a coverage review.

HEPATITISAntivirals

ribasphere ribapak, RibaTab moderiba, ribavirin capsules, ribavirin tablets

Hepatitis C*(genotypes 1 & 4) Note: This category is being reviewed based upon recent product launches.

Daklinza, Olysio, Sovaldi, ZepatierViekira Pak (genotype 1), Technivie (genotype 4)

INFLAMMATORY CONDITIONSTumor Necrosis Factor Antagonists and Other Drugs for Inflammatory Conditions** This product may be reassessed later this year to reflect anticipated product launches.

Cimzia, Kineret (Exclude for RA), Orencia, Simponi 50 MG, Taltz

Actemra**, Cosentyx, Enbrel, Humira, Otezla, Remicade, Simponi 100 MG (for ulcerative colitis only), Stelara, Xeljanz, Xeljanz XR

MUSCULOSKELETAL & RHEUMATOLOGYGout Therapy

Colchicine Colcrys, Mitigare

OBSTETRICAL & GYNECOLOGICALGonadotropin-Releasing Hormone (GnRH) Antagonists (for Infertility)

Ganirelix Acetate Cetrotide

Ovulatory Stimulants (Follitropins) Bravelle, Follistim AQ Gonal-f, Gonal-f RFF, Gonal-f RFF Redi-ject

Vaginal Progesterones Endometrin Crinone 8% Gel

OPHTHALMICAntiglaucoma Drugs(Beta-Adrenergic Blockers)

Istalolbetaxolol drops, levobunolol drops, timolol drops, Alphagan P 0.1%, Combigan

Antiglaucoma Drugs (Ophthalmic Prostaglandins)

Zioptanlatanoprost drops, travoprost drops, Lumigan, Travatan Z

Ophthalmic Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

Acuvailbromfenac drops, diclofenac drops, ketorolac drops, Ilevro, Nevanac, Prolensa

OSTEOARTHRITISHyaluronic Acid Derivatives

Gel-One, Genvisc 850, Hyalgan, Hymovis, Supartz, Supartz FX, Synvisc, Synvisc-One

Euflexxa, Monovisc, Orthovisc

RESPIRATORYPulmonary Anti-Inflammatory Inhalers

AlvescoArnuity Ellipta, Asmanex HFA/Twisthaler, Flovent Diskus/HFA, Pulmicort Flexhaler, QVAR

Short-Acting Beta2-Agonist Inhalers Proventil HFA, Xopenex HFA ProAir HFA/RespiClick, Ventolin HFA

UROLOGICALErectile Dysfunction Oral Agents

Levitra, Staxyn, Stendra Cialis, Viagra

WEIGHT LOSSWeight Loss Agents

Qsymia phentermine

http://express-scripts.com/covered


Active Employee Prescription Drug Benefit Program RETAIL PHARMACY MAIL ORDER PHARMACY

For immediate or short-term medication needs1 For maintenance or long-term medication needs1 YOU WILL PAY • $10 for each generic medication

• $25 for each preferred brand-name medication2

• $40 for each non-preferred brand-namemedication2

• $1 for each generic medication• $40 for each preferred brand-name medication2

• $70 for each non-preferred brand-namemedication2

PREVENTIVE $0 Co-Pay for certain preventive maintenance medications (some age and brand restrictions apply) 3 MAXIMUM

OUT-OF-POCKET $750 per individual per calendar year $1,500 per family per calendar year

DAY SUPPLY LIMIT

Up to a 31-day supply Up to a 90-day supply

REFILL LIMIT One initial fill plus two refills for maintenance or long-term medications. For each additional fill, you will pay 100% of the prescription cost.4

None

PRIOR AUTHORIZATION REQUIRED

Acne Therapy, Amevive, Antiemetic Agents, Apokyn, Botox and Myobloc for Non-Cosmetic Purposes Only, Celebrex, Misc. Dermatologicals, Erectile Dysfunction, Erythroid Stimulants, Growth Hormones, Hypnotic Agents, Interferons, Migraine Agents, Multiple Sclerosis Therapy, Myeloid Stimulants, Platelet Proliferation Stimulants, Provigil, Rheumatoid Arthritis Therapy, Xolair, Wellbutrin and its generics.

1 Your plan may have coverage limits, be subject to dispensing limitations and may not cover certain medications. Please contact Express Scripts at 1-866-544-1798 or log on to Express-Scripts.com for the most up-to-date plan information.

2 When a generic equivalent is available but the pharmacy dispenses the brand-name medication for any reason other than a doctor’s “dispense as written” or equivalent instructions, you will pay the generic copayment plus the difference in cost between the brand-name and generic.

3 Your prescription benefits provide access to certain preventive medications at no cost to you. In some situations, over-the-counter (OTC) medications may also be covered at 100% with a prescription. Preventive medication categories include: women’s preventive services and contraception coverage, smoking cessation, aspirin, fluoride, folic acid, iron supplements, vitamin D, and bowel preparation for colonoscopy screenings. Certain brand, age and gender restrictions apply. Call Member Services toll-free at 1-866-544-1798 to learn more about the eligibility criteria.

4 Your plan requires that maintenance or long-term medications be filled through the Express Scripts PharmacySM Home Delivery Service once you exceed the refill limit per prescription. Your plan also includes the Select Active Choice (Mail Order Opt-Out) Program. For more information, please call Express Scripts toll-free at 1-866-544-1798 to talk with a Member Service Representative about the opt-out program.

Choosing Where to Fill Your Prescription

For short-term medications, such as antibiotics, use a participating retail pharmacy. As a member, you can go to any of nearly 60,000 retail pharmacies, including most major drugstores. Just ask your retail pharmacy if it is in the Express Scripts’ network. You can also log on to Express-Scripts.com and click “Locate a pharmacy” or call Member Services toll-free at 1-866-544-1798. Please note, if you fill a prescription at a non-participating retail pharmacy, you will be responsible for paying 100% of the cost of the medication. You will then need to submit a paper claim form along with the original prescription receipt(s) for reimbursement of covered expenses.

Long-term medications are those medications taken to treat an on-going condition, such as high blood pressure, high cholesterol or diabetes. You will generally save money by using mail order for these prescriptions. Choose one of the three easy ways to start using the Express Scripts PharmacySM Home Delivery Service:

1. Go to StartHomeDelivery.com and register for Express Scripts PharmacySM.2. Contact Member Services toll-free at 1-866-544-1798 and speak to a Patient Care Advocate.3. Fill out and send in a mail service order form found on the Express-Scripts.com website along with your written prescription.

Member Services If you have questions about your prescriptions or benefits, you can contact Member Services 24 hours a day, seven days a week, toll-free at 1-866-544-1798. For Telecommunication Device assistance please call toll-free 1-800-759-1089. Express-Scripts.com is also available to help you manage your prescription drug benefits. By registering online, you can order mail service refills, check order status, price medications, and much more.

Reviewed by RMU 01/01/2017

Day Supply and Refill Limit from a Retail Pharmacy You can get up to a 31-day supply of medication each time you have a prescription filled at a participating retail pharmacy. Ask your doctor to write a prescription for up to a 31-day supply, when clinically appropriate.

You may obtain one initial fill plus two refills for maintenance or long-term medications at a retail pharmacy. It will then be necessary for you to utilize the Express Scripts PharmacySM Home Delivery Service for additional supplies. Otherwise, you will be responsible for 100% of the cost of the medication when filled at a retail pharmacy. To determine if your prescription is classified as maintenance or long-term, please call Member Services at 1-866-544-1798 or log-on to Express-Scripts.com.

Day Supply Limit from Express Scripts PharmacySM Home Delivery (Mail Order Pharmacy) You can get up to a 90-day supply of medication when you get a prescription filled through the Express Scripts PharmacySM Home Delivery Service. Ask your doctor to write a prescription for up to a 90-day supply plus three refills for up to one year when clinically appropriate.

Convenient Home Delivery (Mail Order) Orders are usually processed and mailed within 48 hours of receipt. Please allow 8 days from the day you mail in your prescription. You can check on the status of your order by logging on to Express-Scripts.com. Or you can call Member Services and use the automated system. If you are a first-time visitor to the website, take a moment to register. Have your member ID number handy.

Payment Options When using home delivery, you can pay by check, e-check (see below for additional information), money order or credit card. If you prefer to use a credit card, you have the option of joining Express Scripts’ automatic payment program by calling 1-800-948-8779 or by enrolling online. Credit cards accepted include Visa, MasterCard, Discover, American Express, and Health Reimbursement (HRA) or Flexible Spending Account (FSA) debit cards.


Other Important Plan Information

Express Scripts Formulary Drug List Your plan is subject to a list of prescription drugs that are preferred by the plan because of their safety, clinical effectiveness and ability to help control prescription drug costs. The drug list is updated on a regular basis. Log on to Express-Scripts.com or call Member Services at 1-866-544-1798 to access the most current information for your plan.

Select Active Choice (Mail Order Opt Out) Your plan includes the Select Active Choice (Mail Order Opt Out) program. This program can be used for plan participants who feel that using home delivery service would create undue hardship. The Select Active Choice program gives you the choice of filling your maintenance or long-term prescriptions through the Express Scripts PharmacySM Home Delivery Service or at a retail pharmacy location. If you think filling your maintenance or long-term prescriptions through home delivery will create a hardship for you, please call Express Scripts toll-free at 1-877-603-1032 to talk with a Member Services Representative about the opt-out program or visit Express-Scripts.com/Decide to notify Express Scripts of your decision to opt-out. Please note, you may only receive up to a 31-day supply at a retail pharmacy location and you will be subject to the retail copayment. Even if you elect to opt-out now, you can still choose to use mail service at any time.

Brand Name Medications Requiring the Use of a Generic First (Step Therapy) You can save money by using safe, effective generic medications when possible. Your plan requires using an alternative generic medication for certain brand-name medications first unless you have tried a generic. Brand-name medications will be covered under your plan if your prescription history shows you have tried an alternative generic. Please call Express Scripts toll-free at 1-866-544-1798 to talk with a Member Services Representative about your plan and options available if you must take the brand-name medication because of a medical condition or allergy.

Drug Quantity Management Your plan includes quantity limits for some medications limiting the amount of medication for which your plan will pay. Please call Express Scripts toll-free at 1-866-544-1798 to talk with a Member Services Representative about the limits and options available if your doctor determines additional quantities are clinically appropriate.

Prior Authorization Some medications may require approval before the prescription can be filled. If your prescription requires prior authorization, you or your doctor can initiate the prior authorization review by calling Express Scripts at 1-800-753-2851. Express Scripts will inform you and your doctor in writing of the coverage decision.

Specialty Medications Specialty medications are drugs that are used to treat complex conditions, such as cancer, growth hormone deficiency, hemophilia, hepatitis C, immune deficiency, multiple sclerosis, and rheumatoid arthritis. Whether they are administered by a healthcare professional, self-injected, or taken by mouth, specialty medications require an enhanced level of service. All specialty medications will be provided by Accredo Health Group, Inc., an Express Scripts specialty pharmacy. For more information about Accredo, or to order your specialty medications, call Express Scripts Member Services at 1-866-544-1798.

Reviewed by RMU 01/01/2017


2018 Retiree Prescription Drug Benefit Program Non-Medicare Eligible (Under 65) Plan

RETAIL PHARMACY MAIL ORDER PHARMACY

For immediate or short-term medication needs1 For maintenance or long-term medication needs1

YOU WILL PAY $10 for each generic medication

$25 for each preferred brand-name medication2

$40 for each non-preferred brand-name medication2

$10 for each generic medication

$50 for each preferred brand-name medication2

$80 for each non-preferred brand-name medication2

PREVENTIVE $0 Co-Pay for certain preventive maintenance medications (some age and brand restrictions apply) 3

MAXIMUM OUT-OF-POCKET

$750 per individual per calendar year $1,500 per family per calendar year

DAY SUPPLY LIMIT

Up to a 31-day supply Up to a 90-day supply

REFILL LIMIT One initial fill plus two refills for maintenance or long-term medications. For each additional fill, you will pay 100% of the prescription cost.4

None

PRIOR AUTHORIZATION

REQUIRED

Acne Therapy, Amevive, Antiemetic Agents, Apokyn, Botox and Myobloc for Non-Cosmetic Purposes Only, Celebrex, Misc. Dermatologicals, Erectile Dysfunction, Erythroid Stimulants, Growth Hormones, Hypnotic Agents, Interferons, Migraine Agents, Multiple Sclerosis Therapy, Myeloid Stimulants, Platelet Proliferation Stimulants, Provigil, Rheumatoid Arthritis Therapy, Xolair, Wellbutrin and its generics.

1 Your plan may have coverage limits, be subject to dispensing limitations and may not cover certain medications. Please contact Express Scripts at 1-866-544-1798 or log on to Express-Scripts.com for the most up-to-date plan information.

2 When a generic equivalent is available but the pharmacy dispenses the brand-name medication for any reason other than a doctor’s “dispense as written” or equivalent instructions, you will pay the generic copayment plus the difference in cost between the brand-name and generic.

3 Your prescription benefits provide access to certain preventive medications at no cost to you. In some situations, over-the-counter (OTC) medications may also be covered at 100% with a prescription. Preventive medication categories include: women’s preventive services and contraception coverage, smoking cessation, aspirin, fluoride, folic acid, iron supplements, vitamin D, and bowel preparation for colonoscopy screenings. Certain brand, age and gender restrictions apply. Call Member Services toll-free at 1-866-544-1798 to learn more about the eligibility criteria.

4 Your plan requires that maintenance or long-term medications be filled through the Express Scripts PharmacySM Home Delivery Service once you exceed the refill limit per prescription. Your plan also includes the Select Active Choice (Mail Order Opt-Out) Program. For more information, please call Express Scripts toll-free at 1-866-544-1798 to talk with a Member Service Representative about the opt-out program.

Choosing Where to Fill Your Prescription

For short-term medications, such as antibiotics, use a participating retail pharmacy. As a member, you can go to any of nearly 60,000 retail pharmacies, including most major drugstores. Just ask your retail pharmacy if it is in the Express Scripts’ network. You can also log on to Express-Scripts.com and click “Locate a pharmacy” or call Member Services toll-free at 1-866-544-1798. Please note, if you fill a prescription at a non-participating retail pharmacy, you will be responsible for paying 100% of the cost of the medication. You will then need to submit a paper claim form along with the original prescription receipt(s) for reimbursement of covered expenses.

Long-term medications are those medications taken to treat an on-going condition, such as high blood pressure, high cholesterol or diabetes. You will generally save money by using mail order for these prescriptions. Choose one of the three easy ways to start using the Express Scripts PharmacySM Home Delivery Service:

1. Go to StartHomeDelivery.com and register for Express Scripts PharmacySM. 2. Contact Member Services toll-free at 1-866-544-1798 and speak to a Patient Care Advocate. 3. Fill out and send in a mail service order form found on the Express-Scripts.com website along with your written prescription.

Member Services If you have questions about your prescriptions or benefits, you can contact Member Services 24 hours a day, seven days a week, toll-free at 1-866-544-1798. For Telecommunication Device assistance please call toll-free 1-800-759-1089. Express-Scripts.com is also available to help you manage your prescription drug benefits. By registering online, you can order mail service refills, check order status, price medications, and much more.

Day Supply and Refill Limit from a Retail Pharmacy You can get up to a 31-day supply of medication each time you have a prescription filled at a participating retail pharmacy. Ask your doctor to write a prescription for up to a 31-day supply, when clinically appropriate.

You may obtain one initial fill plus two refills for maintenance or long-term medications at a retail pharmacy. It will then be necessary for you to utilize the Express Scripts PharmacySM Home Delivery Service for additional supplies. Otherwise, you will be responsible for 100% of the cost of the medication when filled at a retail pharmacy. To determine if your prescription is classified as maintenance or long-term, please call Member Services at 1-866-544-1798 or log-on to Express-Scripts.com.

Day Supply Limit from Express Scripts PharmacySM Home Delivery (Mail Order Pharmacy) You can get up to a 90-day supply of medication when you get a prescription filled through the Express Scripts PharmacySM Home Delivery Service. Ask your doctor to write a prescription for up to a 90-day supply plus three refills for up to one year when clinically appropriate.

Convenient Home Delivery (Mail Order) Orders are usually processed and mailed within 48 hours of receipt. Please allow 8 days from the day you mail in your prescription. You can check on the status of your order by logging on to Express-Scripts.com. Or you can call Member Services and use the automated system. If you are a first-time visitor to the website, take a moment to register. Have your member ID number handy.

Payment Options When using home delivery, you can pay by check, e-check (see below for additional information), money order or credit card. If you prefer to use a credit card, you have the option of joining Express Scripts’ automatic payment program by calling 1-800-948-8779 or by enrolling online. Credit cards accepted include Visa, MasterCard, Discover, American Express, and Health Reimbursement (HRA) or Flexible Spending Account (FSA) debit cards.


Other Important Plan Information

Express Scripts Formulary Drug List Your plan is subject to a list of prescription drugs that are preferred by the plan because of their safety, clinical effectiveness and ability to help control prescription drug costs. The drug list is updated on a regular basis. Log on to Express-Scripts.com or call Member Services at 1-866-544-1798 to access the most current information for your plan.

Select Active Choice (Mail Order Opt Out) Your plan includes the Select Active Choice (Mail Order Opt Out) program. This program can be used for plan participants who feel that using home delivery service would create undue hardship. The Select Active Choice program gives you the choice of filling your maintenance or long-term prescriptions through the Express Scripts PharmacySM Home Delivery Service or at a retail pharmacy location. If you think filling your maintenance or long-term prescriptions through home delivery will create a hardship for you, please call Express Scripts toll-free at 1-877-603-1032 to talk with a Member Services Representative about the opt-out program or visit Express-Scripts.com/Decide to notify Express Scripts of your decision to opt-out. Please note, you may only receive up to a 31-day supply at a retail pharmacy location and you will be subject to the retail copayment. Even if you elect to opt-out now, you can still choose to use mail service at any time.

Brand Name Medications Requiring the Use of a Generic First (Step Therapy) You can save money by using safe, effective generic medications when possible. Your plan requires using an alternative generic medication for certain brand-name medications first unless you have tried a generic. Brand-name medications will be covered under your plan if your prescription history shows you have tried an alternative generic. Please call Express Scripts toll-free at 1-866-544-1798 to talk with a Member Services Representative about your plan and options available if you must take the brand-name medication because of a medical condition or allergy.

Drug Quantity Management Your plan includes quantity limits for some medications limiting the amount of medication for which your plan will pay. Please call Express Scripts toll-free at 1-866-544-1798 to talk with a Member Services Representative about the limits and options available if your doctor determines additional quantities are clinically appropriate.

Prior Authorization Some medications may require approval before the prescription can be filled. If your prescription requires prior authorization, you or your doctor can initiate the prior authorization review by calling Express Scripts at 1-800-753-2851. Express Scripts will inform you and your doctor in writing of the coverage decision.

Specialty Medications Specialty medications are drugs that are used to treat complex conditions, such as cancer, growth hormone deficiency, hemophilia, hepatitis C, immune deficiency, multiple sclerosis, and rheumatoid arthritis. Whether they are administered by a healthcare professional, self-injected, or taken by mouth, specialty medications require an enhanced level of service. All specialty medications will be provided by Accredo Health Group, Inc., an Express Scripts specialty pharmacy. For more information about Accredo, or to order your specialty medications, call Express Scripts Member Services at 1-866-544-1798.

(continued)

The following is a list of the most commonly prescribed drugs. It represents an abbreviatedversion of the drug list (formulary) that is at the core of your prescription-drug benefit plan.The list is not all-inclusive and does not guarantee coverage. In addition to using this list,you are encouraged to ask your doctor to prescribe generic drugs whenever appropriate.

PLEASE NOTE: Brand-name drugs may move to nonformulary status if a generic versionbecomes available during the year. Not all the drugs listed are covered by all prescription-drug benefit programs; check your benefit materials for the specific drugs covered andthe copayments for your prescription-drug benefit program. For specific questions aboutyour coverage, please call the phone number printed on your member ID card.

2017 Express ScriptsNational Preferred FormularyFor State of New Hampshire

THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2017 THROUGH DECEMBER 31, 2017. THIS LIST IS SUBJECT TO CHANGE.You can get more information and updates to this document at our website at express-scripts.com.


NP-TPRMT6542NP-17 (09/15/16)

KEY[INJ] - Injectable DrugBrand-name drugs are listed

in CAPITAL letters.Generic drugs are listed in

lower case letters.Not all compounded

medications are covered by the plan.

ANTI-INFECTIVES

Antifungal Agentsfluconazolenystatin oral suspensionAntiviralsacyclovirmoderibaTAMIFLUTECHNIVIEvalacyclovirVIEKIRA PAKCephalosporinscefdinircefuroxime axetilcephalexinErythromycins & OtherMacrolidesazithromycinclarithromycinPenicillinsamoxicillinamoxicillin/potassium

clavulanatepenicillin v potassiumQuinolonesciprofloxacinlevofloxacinTetracyclinesdoxycycline hyclatedoxycycline monohydrateminocyclineORACEASOLODYNUrinary Tract Agentsnitrofurantoin monohydrate/

macrocrystalMisc. Anti-InfectivesBETHKISclindamycin hclhydroxychloroquineKITABIS PAKmetronidazolesulfamethoxazole/

trimethoprimTOBI PODHALERXIFAXAN

ANTINEOPLASTIC &IMMUNOSUPPRESSANTDRUGS

anastrozoleGILOTRIFINLYTAIRESSAmethotrexateSOMATULINE DEPOT [INJ]SPRYCELtamoxifenTARCEVAZYTIGA

AUTONOMIC & CNS DRUGS,NEUROLOGY & PSYCH

Anticonvulsantsclonazepamdivalproex delayed-releasedivalproex ext-releaseFYCOMPAgabapentinGRALISElamotriginelevetiracetamLYRICAoxcarbazepinePOTIGAQUDEXYtopiramateVIMPATAntiparkinsonism AgentsAZILECTcarbidopa/levodopapramipexoleropiniroleMisc. Neurological TherapyAMPYRACOPAXONE 40 MG [INJ]donepezilGILENYANAMENDA XRNAMZARICNUEDEXTATECFIDERAAntipsychoticsaripiprazoleARISTADA [INJ]LATUDAolanzapinequetiapinerisperidoneSEROQUEL XRMisc. PsychotherapeuticAgentsDAYTRANAdexmethylphenidate

ext-releasedextroamphetamine/

amphetaminedextroamphetamine/

amphetamine ext-releaseEVEKEOFOCALIN XR 25 MG, 35 MGguanfacine ext-releasemethylphenidatemethylphenidate ext-releaseQUILLICHEW ERQUILLIVANT XRSTRATTERAVYVANSEAntivertigo & AntiemeticDrugsAKYNZEOmeclizineondansetronondansetron orally

disintegrating tabletsSANCUSOAnxiolyticsalprazolambuspironediazepamlorazepamHypnotic Agentseszopiclonetemazepamzolpidemzolpidem ext-release

Migraine & ClusterHeadache Therapybutalbital/acetaminophen/

caffeineRELPAXrizatriptansumatriptanSUMAVEL DOSEPRO [INJ]ZOMIG NASALNarcotic Analgesicsacetaminophen/codeineBUTRANSfentanyl patchhydrocodone/acetaminophenhydromorphoneHYSINGLA ERLAZANDAmorphine sulfate ext-releaseNUCYNTA, NUCYNTA EROPANA ERoxycodoneoxycodone/acetaminophenOXYCONTINNarcotic AntagonistsNARCAN NASAL SPRAYSUBOXONE SL FILMZUBSOLVNon-Narcotic AnalgesicstramadolMisc. AnalgesicsEUFLEXXA [INJ]MONOVISC [INJ]ORTHOVISC [INJ]Selective SerotoninReuptake InhibitorsBRISDELLEcitalopramescitalopramfluoxetineparoxetinesertralineVIIBRYDTricyclicsamitriptylinenortriptylineMisc. Antidepressantsbupropionbupropion ext-releaseduloxetine delayed-releaseFETZIMAmirtazapinePRISTIQtrazodonevenlafaxinevenlafaxine ext-release

CARDIOVASCULAR,HYPERTENSION & LIPIDS

ACE Inhibitors & Combosbenazeprilenalaprillisinoprillisinopril/hctzquinaprilramiprilAdrenergic Antagonists &Related DrugsclonidinedoxazosinterazosinAngiotensin II ReceptorBlockers & Renin Inhibitors& CombosBENICAR, BENICAR HCTirbesartanlosartan

losartan/hctzTEKAMLOTEKTURNA, TEKTURNA HCTvalsartanvalsartan/hctzAntiarrhythmic AgentsamiodaroneBeta-Blockers & Combosatenololatenolol/chlorthalidonebisoprolol/hctzBYSTOLICcarvedilolCOREG CRlabetalolmetoprolol succinate

ext-releasemetoprolol tartratepropranololpropranolol ext-releaseCalcium Channel Blockersamlodipinediltiazem ext-releasenifedipine ext-releaseverapamil ext-releaseOther AntihypertensiveCombosamlodipine/benazeprilamlodipine/valsartanAZORTRIBENZORCardiac GlycosidesdigoxinLipid/Cholesterol LoweringAgentsatorvastatinfenofibratefenofibrate micronizedfenofibric acid

delayed-releasegemfibrozilLIPOFENLIVALOlovastatinniacin ext-releasePRALUENT [INJ]pravastatinREPATHA [INJ]rosuvastatinsimvastatinVASCEPAVYTORINWELCHOLZETIANitratesisosorbide mononitrate

ext-releaseThiazide & RelatedDiureticschlorthalidonefurosemidehydrochlorothiazide spironolactonetriamterene/hctzMisc. CardiovascularAgentsCORLANORENTRESTOhydralazineMEPHYTONRANEXA

DERMATOLOGICALS/TOPICAL THERAPY

Antipsoriatic/AntiseborrheicCOSENTYX [INJ]

ENSTILARSTELARA [INJ]TACLONEX SUSPENSIONTherapy for AcneABSORICAACANYAclindamycin phosphate clindamycin phosphate/

benzoyl peroxideEPIDUO, EPIDUO FORTEFINACEAmetronidazoleMIRVASOONEXTONSOOLANTRATAZORACTopical AntibacterialsmupirocinTopical Antifungalsclotrimazole/betamethasone

dipropionateketoconazolenystatinTopical AntiviralsZOVIRAX CREAMTopical Corticosteroidsclobetasol propionatedesonidefluocinonidehydrocortisonemometasonetriamcinoloneMisc. DermatologicalsCARACELIDELlidocaine patchesPICATO

EAR, NOSE & THROATMEDICATIONS

Drugs Affecting the EarCIPRODEXneomycin/polymyxin/

hydrocortisoneDrugs Affecting the NoseazelastineDYMISTAfluticasoneQNASLMisc. Agentschlorhexidine gluconate

ENDOCRINE/DIABETES

Adrenal HormonesACTHAR H.P. [INJ]dexamethasonemethylprednisoloneprednisolone sodium

phosphateprednisoneAndrogensANDROGEL 1.62%AXIRONtestosterone cypionate [INJ]Antithyroid AgentsmethimazoleGlucose Elevating AgentsGLUCAGEN [INJ]GLUCAGON [INJ]Gonadotropin & RelatedAgentsCETROTIDE [INJ]chorionic gonadotropin [INJ]

Insulin TherapyHUMALOG [INJ]HUMULIN [INJ]LANTUS [INJ]LEVEMIR [INJ]TOUJEO SOLOSTAR [INJ]TRESIBA [INJ]Non-Insulin HypoglycemicAgentsBYDUREON [INJ]BYETTA [INJ]FARXIGAglimepirideglipizideglipizide ext-releaseglyburideGLYXAMBIINVOKAMETINVOKANAJANUMET, JANUMET XRJANUVIAJARDIANCEJENTADUETOJENTADUETO XRmetforminmetformin ext-releasepioglitazoneSYMLINPEN [INJ]SYNJARDYTRADJENTATRULICITY [INJ]XIGDUO XROvulatory Stimulantsclomiphene citrateGONAL-F, GONAL-F RFF,

GONAL-F RFF REDI-JECT [INJ]

Thyroid Hormoneslevothyroxine sodiumliothyronineBlood Glucose MonitoringDevices & SuppliesONETOUCH KITS/METERS;

ULTRAMINI, VERIO, VERIO FLEX, VERIO IQ,VERIO SYNC

ONETOUCH TEST STRIPS;ULTRA, VERIO

GASTROENTEROLOGY

Antidiarrheals &Antispasmodicsdicyclominediphenoxylate/atropineBowel EvacuantsSUPREPDigestive EnzymesCREONVIOKACEZENPEPH2 AntagonistsfamotidineranitidineProton Pump Inhibitorsesomeprazole magnesium

delayed-releaselansoprazole delayed-releaseNEXIUM PACKETSomeprazole delayed-releasepantoprazole delayed-releaserabeprazole delayed-releaseOther Ulcer TherapyPYLERA


Misc. GastrointestinalAgentsAMITIZAAPRISOCANASALIALDALINZESSmetoclopramide hclMOVANTIKPENTASAPREPOPIKRECTIVRELISTOR [INJ]REMICADE [INJ]SIMPONI 100 MG

(for ulcerative colitisonly) [INJ]

UCERIS TABLETSVIBERZI

IMMUNOLOGY &BIOTECHNOLOGY

Erythroid StimulantsPROCRIT [INJ]Growth HormonesGENOTROPIN [INJ]HUMATROPE [INJ]NORDITROPIN [INJ]InterferonsAVONEX [INJ]EXTAVIA [INJ]PLEGRIDY [INJ]REBIF [INJ]Myeloid StimulantsGRANIX [INJ]NEUPOGEN [INJ]Misc. ImmunologicalsGRASTEKRAGWITEK

MUSCULOSKELETAL &RHEUMATOLOGY

Gout TherapyallopurinolCOLCRYSMITIGAREULORICMuscle Relaxants &Antispasmodic TherapybaclofencyclobenzaprineMESTINON SYRUPmetaxalonemethocarbamoltizanidineNSAID Agentscelecoxibdiclofenac sodium

delayed-releaseetodolacibuprofenindomethacinmeloxicamnabumetonenaproxen, naproxen sodiumZORVOLEXOsteoporosis TherapyalendronateFORTEO [INJ]ibandronateraloxifeneMisc. RheumatologicalAgentsACTEMRA [INJ]ENBREL [INJ]HUMIRA [INJ]OTEZLAOTREXUP [INJ]RASUVO [INJ]SAVELLAXELJANZ, XELJANZ XR

OBSTETRICS & GYNECOLOGY

Estrogen Combosestradiol/norethindrone

acetateCOMBIPATCHDUAVEE

PREMPHASEPREMPROEstrogensDIVIGELENJUVIAESTRACE CREAMestradiolestradiol patchMINIVELLEPREMARIN CREAMPREMARIN TABSOral Contraceptives &Related AgentsNOTE: All genericcontraceptives areconsidered formularyBEYAZLO LOESTRIN FEMINASTRIN 24 FEMIRENANATAZIANUVARINGSAFYRALProgestinsCRINONEMAKENA [INJ]medroxyprogesteroneprogesterone micronizedVaginal Anti-Infectivesmetronidazole gelterconazole

OPHTHALMOLOGY

AntibioticsAZASITEerythromycinlevofloxacinMOXEZApolymyxin/trimethoprim

solutiontobramycinVIGAMOXGlaucoma DrugsALPHAGAN P 0.1%COMBIGANlatanoprost solutionLUMIGANtimolol maleateTRAVATAN ZNon-Steroidal Anti-Inflammatory AgentsILEVRONEVANACPROLENSASteroid-Antibiotic CombosTOBRADEX OINTMENTTOBRADEX STtobramycin/dexamethasone

suspensionZYLETSteroidsALREXLOTEMAXprednisolone acetateMisc. OphthalmologicsBEPREVEPATADAYPAZEORESTASIS

RESPIRATORY, ALLERGY,COUGH & COLD

AdrenergicsEPIPEN, EPIPEN JR [INJ]Antihistaminesdesloratadinehydroxyzine hclhydroxyzine pamoatelevocetirizinepromethazineAntitussive Combosbenzonatatehydrocodone/

chlorpheniraminepolistirex ext-release

hydrocodone/homatropinepromethazine/

dextromethorphan

Inhaled Beta AgonistsalbuterolARCAPTA NEOHALERPERFOROMISTPROAIR HFAPROAIR RESPICLICKSEREVENT DISKUSSTRIVERDI RESPIMATVENTOLIN HFAInhaled CorticosteroidsARNUITY ELLIPTAASMANEX HFAASMANEX TWISTHALERbudesonideFLOVENT DISKUSFLOVENT HFAPULMICORT FLEXHALERQVARMisc. Pulmonary AgentsADCIRCAADEMPASADVAIR DISKUSADVAIR HFAANORO ELLIPTABREO ELLIPTACOMBIVENT RESPIMATDALIRESPDULERAINCRUSE ELLIPTAKALBITOR [INJ]LETAIRISmontelukastOPSUMITSPIRIVA HANDIHALERSPIRIVA RESPIMATSTIOLTO RESPIMATSYMBICORTTRACLEERTUDORZA PRESSAIRUPTRAVI

UROLOGICALS

Anticholinergics &AntispasmodicsGELNIQUEMYRBETRIQoxybutynin ext-releaseTOVIAZVESICAREBenign ProstaticHyperplasia (BPH) TherapyfinasterideRAPAFLOtamsulosin ext-releaseMisc. UrologicalsCIALISMUSEVIAGRA

VITAMINS, HEMATINICS &ELECTROLYTES

AnticoagulantsELIQUISenoxaparin [INJ]FRAGMIN [INJ]PRADAXAwarfarinXARELTOAntiplatelet DrugsBRILINTAclopidogrelEFFIENTZONTIVITYElectrolytespotassium chloride

ext-releaseVitamins & Hematinicscyanocobalamin [INJ]ergocalciferolfolic acidmultivitamins/fluorideNASCOBALprenatal vitamins

MISCELLANEOUS AGENTS

FOSRENOLRENVELAVELTASSA

Excluded Medications With Covered Preferred Alternatives

The following is a list of excluded brand-name medications with covered preferred alternativesthat are on the formulary. Column 1 lists excluded medications. Column 2 lists covered preferredalternatives that can be prescribed.

Excluded Medications Covered Preferred Alternative(s)ABSTRAL fentanyl citrate lozenges, LAZANDAACCU-CHEK METERS/STRIPS ONETOUCH METERS/STRIPSACUVAIL bromfenac, diclofenac, ketorolac, ILEVRO, NEVANAC, PROLENSAADVOCATE METERS/STRIPS ONETOUCH METERS/STRIPSALOGLIPTIN JANUVIA, TRADJENTAALOGLIPTIN/METFORMIN JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XRALVESCO ARNUITY ELLIPTA, ASMANEX HFA/TWISTHALER, FLOVENT DISKUS/HFA,

PULMICORT FLEXHALER, QVARAPIDRA HUMALOGARANESP PROCRITASACOL HD balsalazide disodium, sulfasalazine, APRISO, LIALDA, PENTASABECONASE AQ budesonide, flunisolide, fluticasone, mometasone, QNASLBRAVELLE GONAL-F, GONAL-F RFF, GONAL-F RFF REDI-JECTBREEZE, CONTOUR METERS/STRIPS ONETOUCH METERS/STRIPSCETRAXAL ciprofloxacin ear solution, ofloxacin ear solution, CIPRODEXCIMZIA ACTEMRA, COSENTYX, ENBREL, HUMIRA, OTEZLA, REMICADE,

STELARA, XELJANZ, XELJANZ XRCOLCHICINE COLCRYS, MITIGAREDAKLINZA (EXCLUDED FOR GENOTYPE 1) VIEKIRA PAKDELZICOL balsalazide disodium, sulfasalazine, APRISO, LIALDA, PENTASADIPENTUM balsalazide disodium, sulfasalazine, APRISO, LIALDA, PENTASADOXYCYCLINE 40 MG CAPSULES ORACEADUEXIS ibuprofen + famotidineEMBRACE, VICTORY METERS/STRIPS ONETOUCH METERS/STRIPSENDOMETRIN CRINONE 8% GELEPOGEN PROCRITESTROGEL DIVIGELEVZIO naloxone syringe, NARCAN NASAL SPRAYFENTORA fentanyl citrate lozenges, LAZANDAFLUOROURACIL 0.5% CREAM diclofenac gel, fluorouracil 5% cream, fluorouracil 2% solution,

imiquimod 5% cream, CARAC, PICATOFOLLISTIM AQ GONAL-F, GONAL-F RFF, GONAL-F RFF REDI-JECTFORTESTA ANDROGEL 1.62%, AXIRONFREESTYLE, PRECISION METERS/STRIPS ONETOUCH METERS/STRIPSGANIRELIX ACETATE CETROTIDEGEL-ONE EUFLEXXA, MONOVISC, ORTHOVISCGELSYN-3 EUFLEXXA, MONOVISC, ORTHOVISCGENVISC 850 EUFLEXXA, MONOVISC, ORTHOVISCGLUMETZA metformin extended-releaseHYALGAN EUFLEXXA, MONOVISC, ORTHOVISCHYMOVIS EUFLEXXA, MONOVISC, ORTHOVISCISTALOL betaxolol, levobunolol, timolol, ALPHAGAN P 0.1%, COMBIGANKAZANO JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XRKINERET (EXCLUDED FOR RA) ACTEMRA, ENBREL, HUMIRA, REMICADE, XELJANZ, XELJANZ XRKOMBIGLYZE XR JANUMET, JANUMET XR, JENTADUETO, JENTADUETO XRLEVITRA CIALIS, VIAGRAMESALAMINE 800 MG DELAYED-RELEASE balsalazide disodium, sulfasalazine, APRISO, LIALDA, PENTASAMIRCERA PROCRITNATESTO ANDROGEL 1.62%, AXIRONNESINA JANUVIA, TRADJENTANOVOLIN HUMULINNOVOLOG HUMALOGNUTROPIN AQ GENOTROPIN, HUMATROPE, NORDITROPINOLYSIO VIEKIRA PAK, TECHNIVIEOMNARIS budesonide, flunisolide, fluticasone, mometasone, QNASLOMNITROPE GENOTROPIN, HUMATROPE, NORDITROPINONGLYZA JANUVIA, TRADJENTAORENCIA (IV and SC) ACTEMRA, ENBREL, HUMIRA, REMICADE, XELJANZ, XELJANZ XRPANCREAZE CREON, ZENPEPPERTZYE CREON, ZENPEPPROVENTIL HFA PROAIR HFA/RESPICLICK, VENTOLIN HFAQSYMIA benzphetamine, diethylpropion, phentermine ribasphere ribapak moderiba, ribavirin capsules, ribavirin tabletsRIBATAB moderiba, ribavirin capsules, ribavirin tabletsSAIZEN GENOTROPIN, HUMATROPE, NORDITROPINSIMPONI 50 MG ACTEMRA, COSENTYX, ENBREL, HUMIRA, OTEZLA, REMICADE,

STELARA, XELJANZ, XELJANZ XRSOVALDI (EXCLUDED FOR VIEKIRA PAK, TECHNIVIEGENOTYPES 1 & 4)

STAXYN CIALIS, VIAGRASTENDRA CIALIS, VIAGRASUBSYS fentanyl citrate lozenges, LAZANDASUPARTZ, SUPARTZ FX EUFLEXXA, MONOVISC, ORTHOVISCSYNVISC, SYNVISC-ONE EUFLEXXA, MONOVISC, ORTHOVISCTALTZ COSENTYX, ENBREL, HUMIRA, OTEZLA, REMICADE, STELARATANZEUM BYDUREON, BYETTA, TRULICITYTESTIM ANDROGEL 1.62%, AXIRONTESTOSTERONE GEL ANDROGEL 1.62%, AXIRONTRUETEST, TRUETRACK METERS/STRIPS ONETOUCH METERS/STRIPSULTRESA CREON, ZENPEPUNISTRIP METERS/STRIPS ONETOUCH METERS/STRIPSVELTIN clindamycin/benzoyl peroxide, clindamycin/tretinoin, ACANYA,

ONEXTONVERAMYST budesonide, flunisolide, fluticasone, mometasone, QNASLVICTOZA BYDUREON, BYETTA, TRULICITYVIMOVO omeprazole delayed-release + naproxen sodiumVOGELXO ANDROGEL 1.62%, AXIRONXOPENEX HFA PROAIR HFA/RESPICLICK, VENTOLIN HFAZEPATIER VIEKIRA PAK, TECHNIVIEZETONNA budesonide, flunisolide, fluticasone, mometasone, QNASLZIOPTAN bimatoprost, latanoprost, travoprost, LUMIGAN, TRAVATAN ZZOMACTON GENOTROPIN, HUMATROPE, NORDITROPINZYCLARA diclofenac gel, fluorouracil 5% cream, fluorouracil 2% solution,

imiquimod 5% cream, CARAC, PICATO

THIS DOCUMENT LIST IS EFFECTIVE JANUARY 1, 2017 THROUGH DECEMBER 31, 2017. THIS LIST IS SUBJECT TO CHANGE.You can get more information and updates to this document at our website at express-scripts.com.


NP-TPRMT6542NP-17 (09/15/16)



Continued on back

The excluded medications shown below are not covered on the State of New Hampshire drug list. In most cases, if you fill a prescription for one of these drugs, you will pay the fullretail price.Take action to avoid paying full price. If you’re currently using one of the excluded medications, please ask your doctor to consider writing you a new prescription for one of thefollowing preferred alternatives. Additional covered alternatives may be available. Costs for covered alternatives may vary. Log on to express-scripts.com/covered to compare drugprices. Not all the drugs listed are covered by all prescription plans; check your benefit materials for the specific drugs covered and the copayments for your plan. For specificquestions about your coverage, please call the number on your member ID card.Express Scripts manages your prescription plan for your employer, plan sponsor, health plan or benefit fund.

AUTONOMIC & CENTRAL NERVOUS SYSTEMAnti-Migraine Therapy

Sumavel Dosepro sumatriptan injection

Duchenne Muscular Dystrophy (DMD) AgentsEmflaza prednisone solution, prednisone tablets

Exondys 51 No alternatives recommended

Long-Acting Opioid Oral Analgesics Opana ER, Oxycodone ERhydromorphone ER, morphine sulfate ER, oxymorphone ER, Hysingla ER, Nucynta ER, Oxycontin

Narcotic Analgesics Buprenorphine Patches, Butransfentanyl patches, hydromorphone ER, morphine sulfate ER, oxymorphone ER, Hysingla ER, Nucynta ER, Oxycontin

Narcotic Antagonists Evzio naloxone syringe, Narcan Nasal Spray

Transmucosal Fentanyl Analgesics Abstral, Fentora, Lazanda fentanyl citrate lozenges

DERMATOLOGICALOral Agents For Rosacea

Doxycycline 40 MG Capsules Oracea

Topical Acne/Antibiotic Combinations Aktipak, Veltinclindamycin/benzoyl peroxide, clindamycin/tretinoin, erythromycin/benzoyl peroxide, Acanya, Onexton

Topical Agents for Actinic Keratosis Fluorouracil 0.5% Cream, Zyclaradiclofenac 3% gel, fluorouracil 2% solution, fluorouracil 5% cream, imiquimod 5% cream, Carac, Picato

DIABETESBlood Glucose Meters & Test Strips

Abbott (FreeStyle, Precision), Bayer (Breeze, Contour), National Medical (Advocate), Omnis Health (Embrace, Victory), Roche (Accu-Chek), Trividia (TRUEtest, TRUEtrack), UniStrip

LifeScan (OneTouch)

Dipeptidyl Peptidase-4 Inhibitors & CombinationsAlogliptin, Nesina, Onglyza Januvia, Tradjenta

Alogliptin/Metformin, Kazano, Kombiglyze XR Janumet, Janumet XR, Jentadueto, Jentadueto XR

Glucagon-Like Peptide-1 Agonists Adlyxin, Tanzeum, Victoza Bydureon, Byetta, Trulicity

InsulinsNovolin Humulin

Apidra, NovoLog Humalog

EAR/NOSENasal Steroids

Beconase AQ, Omnaris, Zetonna budesonide, flunisolide, fluticasone, mometasone, Qnasl

Otic Fluoroquinolone Antibiotics Cetraxalciprofloxacin ear solution, ofloxacin ear solution, Ciprodex, Otovel

ENDOCRINE (OTHER)Estrogen and Estrogen Modifiers for Vaginal Symptoms

Femringestradiol patches, estradiol tablets, yuvafem, Estrace Cream, Estring, Premarin Cream, Premarin Tablets

Growth HormonesNutropin AQ, Nutropin AQ Nuspin, Omnitrope, Saizen, SaizenPrep, Zomacton

Genotropin, Humatrope, Norditropin

Somatostatin Analogs Sandostatin LAR Depot, Signifor LAR Somatuline Depot

Topical Estrogen Gels Estrogel Divigel

Topical Testosterone Products Fortesta, Natesto, Testim, Testosterone Gel, Vogelxo AndroGel 1.62%

GASTROINTESTINALInflammatory Bowel Agents

Asacol HD, Delzicol, Dipentum, Mesalamine 800 MG Delayed-Release

balsalazide disodium, mesalamine 1.2 gm delayed release, sulfasalazine, Apriso, Pentasa

Irritable Bowel Syndrome and Chronic Constipation Agents Trulance Amitiza, Linzess

Pancreatic Enzymes Pancreaze, Pertzye, Ultresa Creon, Zenpep

Proton Pump InhibitorsAciphex Sprinkle, Prevacid Solutab, Prilosec Suspension, Protonix Suspension

esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole, Nexium Packets

HEMATOLOGICALErythropoiesis-Stimulating Agents

Aranesp, Epogen, Mircera Procrit

Granulocyte Colony Stimulating Factors Neupogen Granix, Zarxio

HEPATITISHepatitis C

Daklinza, Olysio, Sovaldi, ZepatierEpclusa, Harvoni, Mavyret, Technivie, Viekira Pak, Viekira XR, Vosevi

2018 State of New Hampshire Preferred Drug List Exclusions

http://express-scripts.com/covered

© 2017 Express Scripts Holding Company. All Rights Reserved. Other trademarks are the property of their respective owners. DL44109Q-6542-18 204612 (09/15/2017)


Excluded Medications/Products at a GlanceAbbott (Freestyle, Precision)AbilifyÂbstralAciphexÂciphex SprinkleAcuvailAdderallÂdlyxinAktipakAlogliptinAlogliptin/MetforminAlvescoAndrogel 1%Ânusol-HCÂpidraAranespAsacol HDAtacand^, Atacand HCTÂuvi-QAzor^Bayer (Breeze, Contour)Beconase AQBenicar^, Benicar HCT^BravelleBupap^Buprenorphine Patches

ButransCetraxalColchicineCymbalta^Cytomel^DaklinzaDelzicolDipentumDoxycycline 40 MG CapsulesEffexor XRÊmflazaEndometrinEpinephrine Auto-Injector

(by A-S Medications, Impax & Lineage)

EpogenEstrogelEvzioExondys 51FemringFentoraFluorouracil 0.5% CreamFollistim AQForteoFortestaFosrenol

Ganirelix AcetateGel-OneGelsyn-3Genvisc 850Glumetza^HyalganHymovisImitrexÎnderal LAÎntunivÎstalolKazanoKombiglyze XRLazandaLevalbuterol HFALevitraLexapro^Librax^Lidoderm^Lovenox^Lunesta^Mesalamine 800 MG

Delayed-ReleaseMinastrin 24 Fe^MirceraNasonex^

NatestoNational Medical (Advocate)NesinaNeupogenNevanacNovolinNovologNutropin AQ,

Nutropin AQ NuspinOlysioOmnarisOmnis Health

(Embrace, Victory)OmnitropeOnglyzaOpana EROxycodone ERPancreazePertzyePlaquenil^Plavix^Prevacid^Prevacid SolutabPrilosec SuspensionPristiq^Protonix^

Protonix SuspensionProventil HFAProvigil^Prozac^Pulmicort Respules^QsymiaRenagelRoche (Accu-Chek)Saizen, SaizenPrepSandostatin LAR DepotSeroquel^, Seroquel XR^Signifor LARSingulair^SovaldiStaxynStendraStrattera^Sumavel DoseproSupartz, Supartz FXSynvisc, Synvisc-OneTanzeumTestimTestosterone GelTikosyn^Timoptic OcudoseTobi Solution^

Tribenzor^Trividia (Truetest, Truetrack)TrulanceUltresaUnistripValium^Valtrex^VeltinVictozaVogelxoVytorin^Wellbutrin SR^Xanax^, Xanax XR^Xenazine^Xopenex HFAZegerid^ZepatierZetia^ZetonnaZioptanZoloft^ZomactonZyclaraZyflo CR^

^ Multisource brand exclusion – The generic equivalent of this brand-name medication is covered under your plan. FDA-approved generic medications meet strict standards and contain the sameactive ingredients as their corresponding brand-name medications, although they may have a different appearance.

Drug Class Nonpreferred Medications Preferred Alternatives

Indication Based Management

MUSCULOSKELETAL & RHEUMATOLOGYGout Therapy

Colchicine Colcrys, Mitigare

Osteoporosis Therapy Forteo Tymlos

OBSTETRICAL & GYNECOLOGICALGonadotropin-Releasing Hormone (GnRH) Antagonists (for Infertility)

Ganirelix Acetate Cetrotide

Ovulatory Stimulants (Follitropins) Bravelle, Follistim AQ Gonal-f, Gonal-f RFF, Gonal-f RFF Redi-ject

Vaginal Progesterones Endometrin Crinone 8% Gel

OPHTHALMICAntiglaucoma Drugs (Beta-Adrenergic Blockers)

Istalol, Timoptic Ocudosebetaxolol drops, levobunolol drops, timolol drops, Alphagan P 0.1%, Combigan

Antiglaucoma Drugs (Ophthalmic Prostaglandins) Zioptan bimatoprost drops, latanoprost drops, Lumigan, Travatan Z

Ophthalmic Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Acuvail, Nevanacbromfenac drops, diclofenac drops, ketorolac drops, Ilevro, Prolensa

OSTEOARTHRITISHyaluronic Acid Derivatives

Gel-One, Gelsyn-3, Genvisc 850, Hyalgan, Hymovis, Supartz, Supartz FX, Synvisc, Synvisc-One

Euflexxa, Monovisc, Orthovisc

RENAL DISEASEPhosphate Binders

Fosrenol, Renagel sevelamer carbonate, Phoslyra, Renvela Tablets, Velphoro

RESPIRATORYEpinephrine Auto-Injector Systems

Auvi-Q, Epinephrine Auto-Injector (by A-S Medication, Impax & Lineage)

Epinephrine Auto-Injector (by Mylan), EpiPen, EpiPen Jr

Pulmonary Anti-Inflammatory Inhalers AlvescoArmonAir RespiClick, Arnuity Ellipta, Asmanex HFA/Twisthaler, Flovent Diskus/HFA, Pulmicort Flexhaler, QVAR

Short-Acting Beta2-Agonist Inhalers Levalbuterol HFA, Proventil HFA, Xopenex HFA ProAir HFA/RespiClick, Ventolin HFA

UROLOGICALErectile Dysfunction Oral Agents

Levitra, Staxyn, Stendra Cialis, Viagra

WEIGHT LOSSWeight Loss Agents

Qsymia benzphetamine, diethylpropion, phentermine

INFLAMMATORY CONDITIONS** Please note that product placement for this class is under consideration and changes may occur based upon changes in market dynamics and new product launches.

All other Brand Name medications for Inflammatory Conditions* are Nonpreferred. Approval may be granted following a coverage review. A trial of one or more Preferred medications is required prior to initiating therapy with a Nonpreferred medication. A formulary exception may be granted for patients already established on therapy with a Nonpreferred medication.

Actemra, Cosentyx, Enbrel, Humira, Otezla, Remicade, Simponi 100 MG (for ulcerative colitis only), Stelara SC, Xeljanz, Xeljanz XR

CRP17_0179 B00NPA8A

State of New Hampshire Medicare Part D Plan

Benefit Overview

Express Scripts Medicare® (PDP) for The State of New Hampshire Retirees

YOUR 2018 PRESCRIPTION DRUG PLAN BENEFIT Here is a summary of what you will pay for covered prescription drugs across the different stages of your Medicare Part D benefit. You can fill your covered prescriptions at a network retail pharmacy or through our home delivery service. Some network retail pharmacies in your plan will only dispense a one-month supply, while CVS as well as select independent local pharmacies will provide up to a 90-day supply. Please visit our website at www.express-scripts.com or call Express Scripts Medicare Customer Service for more information.

Plan Premium

Your group benefits administrator will tell you the amount that you pay for your plan. If you have any questions, please contact your group benefits administrator.

Member Out-of-Pocket Maximum

You are only responsible for paying applicable copayments for your medications. The plan you have today has a yearly member out-of-pocket maximum (costs paid by yourself only) of $750. If your total copayments reach this amount at any point during a calendar year, you will pay $0 for your covered prescription drugs for the remainder of the plan year. As you move through the Part D stages outlined below, the most you will be subject to paying is the applicable copayments up to the $750 out-of-pocket maximum.

Initial Coverage stage

During the Initial Coverage stage, you will pay the applicable copayment amount until you reach the member out-of-pocket maximum of $750 or until your total yearly drug costs (what you and the plan pay) reach $3,750, whichever comes first. Remember, the most that will come out of your pocket is $750 in a calendar year.

Tier

Retail One-Month

(31-day) Supply

Retail Three-Month

(90-day) Supply*

Home Delivery Three-Month (90-day) Supply

Tier 1: Generic Drugs

$10 copayment

$30 copayment*

$10 copayment

Tier 2: Preferred Brand Drugs

$25 copayment

$75 copayment*

$50 copayment Tier 3: Non-Preferred Brand Drugs

$40 copayment

$120 copayment*

$80 copayment

*Some retail pharmacies in your plan only provide a one-month supply of your covered prescriptions at the one-month supply cost-share. You may receive up to a 90-day supply of certain maintenance drugs (medications taken on a long-term basis) by mail through the Express Scripts PharmacySM. There is no charge for standard shipping. Not all drugs are available at a 90-day supply.

Coverage Gap stage

If you have not met the member out-of-pocket maximum of $750, but your total yearly drug costs (what you and the plan pay) reach $3,750, you will continue to pay the applicable copayment amount as outlined in the Initial Coverage stage until your yearly out-of-pocket drug costs reach $5,000. Remember, the most that will come out of your pocket is $750 in a calendar year.

Catastrophic Coverage stage

If you have not met your member out-of-pocket maximum of $750, but your yearly out-of-pocket drug costs exceed $5,000, you will pay the greater of 5% coinsurance or:

• a $3.35 copayment for covered generic drugs (including brand drugs treated as generics), with a maximum not to exceed the standard copayment during the Initial Coverage stage outlined above

• an $8.35 copayment for all other covered drugs, with a maximum not to exceed the standard copayment during the Initial Coverage stage outlined above.

At this stage of Part D coverage, you may be paying less than the applicable copayment amount for each of your medications until you reach the $750 out-of-pocket maximum.

Long-Term Care (LTC) Pharmacy If you reside in an LTC facility, you pay the same as at a network retail pharmacy. LTC pharmacies must dispense brand-name drugs in amounts of 14 days or less at a time. They may also dispense less than a one month’s supply of generic drugs at a time. Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed. Out-of-Network Coverage You must use Express Scripts Medicare network pharmacies to fill your prescriptions. Covered Medicare Part D drugs are available at out-of-network pharmacies only in special circumstances, such as illness while traveling outside of the plan’s service area where there is no network pharmacy. You generally have to pay the full cost for drugs received at an out-of-network pharmacy at the time you fill your prescription. You can ask us to reimburse you for our share of the cost. Please contact Express Scripts Medicare Customer Service at the numbers on the back of this document for more details.

IMPORTANT PLAN INFORMATION • The service area for this plan is all 50 states, the District of Columbia, Puerto Rico, the

U.S. Virgin Islands, Guam, the Northern Mariana Islands and American Samoa. You must live in one of these areas to participate in this plan.

• You are eligible for this plan if you are entitled to Medicare Part A and/or are enrolled in Medicare Part B, are a U.S. citizen or are lawfully present in the United States, and are eligible for benefits from the State of New Hampshire.

• The amount you pay may differ depending on what type of pharmacy you use; for example, retail, home infusion, LTC or home delivery.

• If your doctor prescribes less than a full month’s supply of certain drugs, you will pay a daily cost-sharing rate based on the actual number of days of the drug that you receive.

• To find a network pharmacy near you, visit our website at www.express-scripts.com. • Your plan uses a formulary – a list of covered drugs. The amount you pay depends on the drug’s

tier and on the coverage stage that you’ve reached. From time to time, a drug may move to a different tier. If a drug you are taking is going to move to a higher (or more expensive) tier, or if the change limits your ability to fill a prescription, Express Scripts will notify you before the change is made.

Please note: The State of New Hampshire determines the copayment amounts you pay for each coverage tier, i.e., Generic, Preferred or Non-Preferred, as outlined under the Initial Coverage stage above. Express Scripts Medicare determines the drugs that are assigned to each coverage tier.

• To access your plan’s list of covered drugs, visit our website at www.express-scripts.com. • The plan may require you to first try one drug to treat your condition before it will cover another

drug for that condition. • Your healthcare provider must get prior authorization from Express Scripts Medicare for you for

certain drugs. • If the actual cost of a drug is less than the normal copayment amount for that drug, you will pay

the actual cost, not the higher copayment amount. • If you request an exception for a drug and Express Scripts Medicare approves the exception,

you will pay the Non-Preferred Brand Drug cost-share for that drug. • You must continue to pay your Medicare Part B premium, if not otherwise paid for under

Medicaid or by another third party.

For a complete explanation of your plan benefits, contact Express Scripts Medicare Customer Service at the numbers on the back of this document.

Does my plan cover Medicare Part B or non–Part D drugs? In addition to providing coverage of Medicare Part D drugs, this plan provides coverage for Medicare Part B medications, as well as for some other drugs that Medicare normally does not cover (non–Part D medications). The amounts paid for Medicare Part B or non-Part D medications by either you or the plan will not accumulate toward your Medicare Part D total drug costs used to advance you through the stages of Part D coverage outlined above. However, they will accumulate toward your State of New Hampshire Express Scripts Medicare $750 out-of-pocket maximum. Please call Customer Service for additional information about specific drug coverage and your copayment amount. Read the Medicare & You 2018 handbook. The Medicare & You handbook has a summary of Original Medicare benefits, rights and protections, and answers to the most frequently asked questions about Medicare. You can get a copy at the Medicare website (https://www.medicare.gov) or by calling 1.800.MEDICARE (1.800.633.4227), 24 hours a day, 7 days a week. TTY users should call 1.877.486.2048.

This information is not a complete description of benefits. Contact Express Scripts Medicare for more information. Limitations, copayments and restrictions may apply. Benefits, premium and/or copayments/coinsurance may change on January 1 of each year. The formulary and/or pharmacy network may change at any time. You will receive notice when necessary. This document may be available in braille. Please call Customer Service at the phone numbers listed above for assistance.

For questions about premiums, enrollment and eligibility, please contact the State of New Hampshire, Office of Risk & Benefits at 1.603.271.1432 or email at [email protected].

Express Scripts Medicare (PDP) is a prescription drug plan with a Medicare contract. Enrollment in Express Scripts Medicare depends on contract renewal.

© 2017 Express Scripts Holding Company. All Rights Reserved. Express Scripts and “E” Logo are trademarks of Express Scripts Holding Company and/or its subsidiaries. Other trademarks are the property of their respective owners.

Express Scripts Medicare Customer Service

1.844.468.0427

24 hours a day, 7 days a week

We have free language interpreter services available for non-English speakers.

TTY: 1.800.716.3231

You can also visit us on the Web at www.express-scripts.com.