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SISC CO-PAYMENT REFERENCE GUIDE
Medco manages your prescription drug benefit at the request of SISC. Your plan gives you
the option of getting your covered medications through the Medco Pharmacy™ mail-order
service or at a participating retail pharmacy.
Your plan features a list of generic and brand-name drugs called the Preferred Prescriptions®
drug list. This list includes a wide selection of medications manufactured by all the major
drug companies. These medications have been selected by an independent group of doctors
and pharmacists for safety and efficacy. The list includes only medications approved by the
U.S. Food and Drug Administration.
These medications are “preferred” because they offer you choice while helping to keep the
cost of your prescription drug benefit affordable. “Non-preferred” drugs, which are not on this
list, will cost you and your plan more. Your doctor can help you save money by prescribing
generic drugs or preferred brand-name drugs. Be sure to bring the Preferred Prescriptions
drug list with you each time you visit your doctor. You can also visit us online at
www.medco.com to get the most up-to-date formulary information. After registering, click on
“Learn about formularies” in the “Prescriptions & benefits” section. You can search for
medications by name or by category and print out information to share with your doctor.
The chart below provides a summary of your prescription drug benefit co-payments.
Type of medication
When you use a participating
When you use the
retail pharmacy, you pay:
Medco Pharmacy, you pay:
$5 co-payment
$10 co-payment
$15 co-payment
$30 co-payment
$30 co-payment
$75 co-payment
*A generic drug will always be dispensed if one is available. If you purchase a brand-name drugwhen a generic alternative is available, you will pay the generic co-payment plus the difference incost between the brand and the generic, even if your doctor writes “dispense as written” (DAW) on the prescription. When you visit a participating retail pharmacy and present your member ID card, you will pay the
applicable cost share and receive up to a 30-day supply of the prescribed drug. For medication
you take on an ongoing basis, using the Medco Pharmacy offers you convenience and potential
cost savings. You can get more information about the Medco Pharmacy mail-order service by
calling 1 800 MEDCO-MAIL (1 800 633-2662).
If you have Internet access, you can visit us online at www.medco.com. After registering, you
can access information about your benefits, as well as health and wellness resources. You may
also contact Member Services toll-free at 1 800 987-5241. Medco looks forward to meeting all
of your prescription benefit needs.
Medications that are not covered by your drug plan
Listed below are medications and medication categories that are not covered under your
SISC drug plan. The list may not reflect all non-covered drugs and may be subject to change.
To confirm whether a prescription drug you need to take is covered or to check the cost of a
medication, visit www.medco.com and click “Price a medication.” (If you’re a first-time visitor
to the site, please take a moment to register. You’ll need your member ID number and the
number from a recent prescription.) You can also get coverage and pricing information by
calling Medco Member Services toll-free at 1 800 987-5241.
Please note that this list may not be all-inclusive.
• Anti-wrinkle agents (Renova®, Retin-A®, and Avita® for patients aged 36 and over)• Experimental drugs• Fertility medications (Follistim®, Gonal-f ®, Clomid®, and Repronex®)• Influenza treatments (for example, Relenza® and Tamiflu®)• Medications labeled “Caution—limited by federal law to investigational use”• Over-the-counter medications (except Prilosec OTC®)• Pigmenting/depigmenting agents (hydroquinone, Eldopaque®, and Eldoquin®)• Hair growth and hair removal agents (Propecia® and Vaniqa®)• Smoking-cessation agents (Nicorette®, Zyban®, Chantix™, and all nicotine patches)• Vitamins (except prescription strengths of prenatal vitamins, hematinics, Rocaltrol®, • Brand non-sedating antihistamines (for example, Clarinex®, Clarinex-D®, and Xyzal®) (See the reverse side for your plan’s co-payment reference guide.)

Source: http://www.lcusd.net/cms/lib04/CA01000868/Centricity/Domain/158/SISC-Medco_RX_5-15-30-_Eff._10-1-11.pdf