State of Texas and Higher Education Employees & Retirees 2009 Pharmacy Information

FY 2009

State of Texas and Higher Education

Employees, Retirees and their Dependents

Prescription Drug Benefit Summary

The Scott & White Health Plan uses a formulary (a list of drugs) that has been selected by a committee of Scott & White Physicians and Pharmacists. These medications are selected based on research that shows their safety and effectiveness. Since there can be many different brands of similar prescription medicines, the formulary is used to select the medication that proves to be most effective in treating an illness.

Benefit Description	Member's Copayment FY 2009
Plan Year Deductible	$50 per person per plan year
If a Brand Name medication is dispensed when a Generic is available, member will be responsible for the Generic Copayment plus the cost difference between the Generic and the Brand Name medication.
Participating Retail Pharmacy -Tier 1/Tier 2/Tier 3
Up to 30-day supply per prescription or refill of Non-Maintenance medication	$10/$25/$40
Up to a 30-day supply per prescription or refill of Maintenance medication	$15/$35/$55
Infertility drugs are paid at 50% copayment	50%
Up to a 30-day supply of insulin for one copayment	$10/$25/$40
Up to a 30-day supply of each diabetic oral agent for one copayment	$10/$25/$40
The supply of necessary disposable syringes for the insulin supply for one copayment	$25
This benefit also includes diabetic supplies other than insulin, diabetic oral agent(s), and syringes as specified in Section 1358.051(2), Tex. Ins. Code. Up to a 30-day supply for a 20% copayment	20%
Mail Order Pharmacy -Tier 1/Tier 2/Tier 3
Up to a 90-day supply per prescripton or refill for one mail order copayment.	$30/$75/$120
Oral contraceptives up to a 90-day supply for one mail order copayment	$30/$75/$120
Infertility drugs are paid at 50% copayment	50%
Up to a 90-day supply of insulin for one mail order copayment	$30/$75/$120
Up to a 90-day supply of each diabetic oral agent for one mail order copayment	$30/$75/$120
The supply of necessary disposable syringes for the insulin supply for one mail order copayment	$75
This benefit also includes diabetic supplies other than insulin, diabetic oral agent(s), and syringes as specified in Section 1358.051(2), Tex. Ins. Code. Up to a 90-day supply for a 20% copayment	20%