22 CSR 10-2.090 - [Effective 6/29/2025] Pharmacy Benefit Summary
(1) The
pharmacy benefit provides coverage for prescription drugs. Vitamin and nutrient
coverage is limited to prenatal agents, therapeutic agents for specific
deficiencies and conditions, and hematopoietic agents as prescribed by a
provider to non-Medicare primary members.
(A)
PPO 750 Plan and PPO 1250 Plan.
1. Network:
A. Preferred formulary generic drug
copayment: ten dollars ($10) for up to a thirty-one- (31-) day supply; twenty
dollars ($20) for up to a sixty- (60-) day supply; and thirty dollars ($30) for
up to a ninety- (90-) day supply for a generic drug on the formulary;
B. Preferred formulary brand drug copayment:
forty dollars ($40) for up to a thirty-one- (31-) day supply; eighty dollars
($80) for up to a sixty- (60-) day supply; and one hundred twenty dollars
($120) for up to a ninety- (90-) day supply for a brand drug on the
formulary;
C. Non-preferred
formulary drug and approved excluded drug copayment: one hundred dollars ($100)
for up to a thirty-one- (31-) day supply; two hundred dollars ($200) for up to
a sixty- (60-) day supply; and three hundred dollars ($300) for up to a ninety-
(90-) day supply for a drug not on the formulary;
D. Specialty drug copayment: seventy-five
dollars ($75) for up to a thirty-one- (31-) day supply for a specialty drug on
the formulary;
E. Diabetic drug (as
designated as such by the PBM) copayment: fifty percent (50%) of the applicable
network copayment;
F. Ninety- (90-)
day supply of prescriptions may be filled through the pharmacy benefit
manager's (PBM's) home delivery program or at select retail pharmacies, as
designated by the PBM;
G. Home
delivery programs.
(I) Maintenance
prescriptions may be filled through the PBM's home delivery program.
(II) Specialty drugs are covered only through
the specialty home delivery network for up to a thirty-one- (31-) day supply
unless the PBM has determined that the specialty drug is eligible for up to a
ninety- (90-) day supply. All specialty prescriptions must be filled through
the PBM's specialty pharmacy, unless the prescription is identified by the PBM
as emergent. The first fill of a specialty prescription identified to be
emergent, may be filled through a retail pharmacy.
(a) Specialty split-fill program-The
specialty splitfill program applies to select specialty drugs as determined by
the PBM. For the first three (3) months, members will be shipped a fifteen-
(15-) day supply and charged a prorated copayment. If the member is able to
continue with the medication, the remaining supply will be shipped and the
member will be charged the remaining portion of the copayment. Starting with
the fourth month, an up to thirty-one- (31-) day supply will be shipped if the
member continues on treatment.
(III) Prescriptions filled through home
delivery programs have the following copayments:
(a) Preferred formulary generic drug
copayments: ten dollars ($10) for up to a thirty-one- (31-) day supply; twenty
dollars ($20) for up to a sixty- (60-) day supply; and twenty-five dollars
($25) for up to a ninety- (90-) day supply for a generic drug on the
formulary;
(b) Preferred formulary
brand drug copayments: forty dollars ($40) for up to a thirty-one- (31-) day
supply; eighty dollars ($80) for up to a sixty- (60-) day supply; and one
hundred dollars ($100) for up to a ninety- (90-) day supply for a brand drug on
the formulary;
(c) Non-preferred
formulary drug and approved excluded drug copayments: one hundred dollars
($100) for up to a thirty-one- (31-) day supply; two hundred dollars ($200) for
up to a sixty- (60-) day supply; and two hundred fifty dollars ($250) for up to
a ninety- (90-) day supply for a drug not on the formulary;
(d) Specialty drug copayment: seventy-five
dollars ($75) for up to a thirty-one- (31-) day supply; one hundred fifty
($150) for up to sixty (60-) day supply; and two hundred twenty-five ($225) for
up to ninety- (90-) day supply for a specialty drug on the formulary;
H. Diabetic drug (as
designated as such by the PBM) copayment: fifty percent (50%) of the applicable
network copayment;
I. Only one (1)
copayment is charged if a combination of different manufactured dosage amounts
must be dispensed in order to fill a prescribed single dosage amount;
J. The copayment for a compound drug is based
on the primary drug in the compound. The primary drug in a compound is the most
expensive prescription drug in the mix. If any ingredient in the compound is
excluded by the plan, the compound will be denied;
K. If the copayment amount is more than the
cost of the drug, the member is only responsible for the cost of the
drug;
L. If the physician allows
for generic substitution and the member chooses a brand-name drug, the member
is responsible for the generic copayment and the cost difference between the
brand-name and generic drug which shall not apply to the out-of-pocket
maximum;
M. Preferred select brand
drugs, as determined by the PBM: ten dollars ($10) for up to a thirty-one-
(31-) day supply; twenty dollars ($20) for up to a sixty- (60-) day supply; and
twenty-five dollars ($25) for up to a ninety- (90-) day supply; and
N. Prescription drugs and prescribed
over-the-counter drugs as recommended by the U.S. Preventive Services Task
Force (categories A and B) and, for women, by the Health Resources and Services
Administration are covered at one hundred percent (100%) when filled at a
network pharmacy. The following are also covered at one hundred percent (100%)
when filled at a network pharmacy:
(I) Vaccine
recommended by the Advisory Committee on Immunization Practices of the Centers
for Disease Control and Prevention;
(II) Prescribed preferred diabetic test
strips and lancets; and
(III) One
(1) preferred glucometer.
2. Non-network: If a member chooses to use a
non-network pharmacy for non-specialty prescriptions, s/he will be required to
pay the full cost of the prescription and then file a claim with the PBM. The
PBM will reimburse the cost of the drug based on the network discounted amount
as determined by the PBM, less the applicable network copayment.
3. Out-of-pocket maximum.
A. Network and non-network out-of-pocket
maximums are separate.
B. The
family out-of-pocket maximum is an aggregate of applicable charges received by
all covered family members of the plan. Any combination of covered family
member applicable charges may be used to meet the family out-of-pocket maximum.
Applicable charges received by one (1) family member may only meet the
individual out-of-pocket maximum amount.
C. Network individual-four thousand one
hundred fifty dollars ($4,150).
D.
Network family-eight thousand three hundred dollars ($8,300).
E. Non-network-no maximum.
(B) Health Savings
Account (HSA) Plan Prescription Drug Coverage. Medical and pharmacy expenses
are combined to apply toward the appropriate network or non-network deductible
and out-of-pocket maximum specified in 22 CSR 102.053.
1. Network:
A. Preferred formulary generic drug: ten
percent (10%) coinsurance up to fifty dollars ($50) per thirty-one- (31-) day
supply after deductible has been met for a generic drug on the
formulary;
B. Preferred formulary
brand drug: twenty percent (20%) coinsurance up to one hundred dollars ($100)
per thirty-one-(31-) day supply after deductible has been met for a brand drug
on the formulary;
C. Non-preferred
formulary drug and approved excluded drug: forty percent (40%) coinsurance up
to two hundred dollars ($200) after deductible has been met;
D. Diabetic drug (as designated as such by
the PBM) coinsurance: fifty percent (50%) of the applicable network
coinsurance, not to exceed:
(I) Twenty-five
dollars ($25) per thirty-one- (31-) day supply for generic drugs;
(II) Fifty dollars ($50) per thirty-one-
(31-) day supply for preferred formulary brand drug; and
(III) One hundred dollars ($100) per
thirty-one- (31-) day supply for non-preferred formulary drug;
E. Ninety- (90-) day supply of
prescriptions may be filled through the pharmacy benefit manager's (PBM's) home
delivery program or at select retail pharmacies, as designated by the
PBM;
F. Home delivery programs.
(I) Maintenance prescriptions may be filled
through the PBM's home delivery program.
(II) Specialty drugs are covered only through
the specialty home delivery network for up to a thirty-one- (31-) day supply
unless the PBM has determined that the specialty drug is eligible for up to a
ninety- (90-) day supply. All specialty prescriptions must be filled through
the PBM's specialty pharmacy, unless the prescription is identified by the PBM
as emergent. The first fill of a specialty prescription identified to be
emergent, may be filled through a retail pharmacy.
(a) Specialty split-fill program-The
specialty splitfill program applies to select specialty drugs as determined by
the PBM. For the first three (3) months, members will be shipped a fifteen-
(15-) day supply. If the member is able to continue with the medication, the
remaining supply will be shipped. Starting with the fourth month, an up to
thirty-one-(31-) day supply will be shipped if the member continues on
treatment;
G.
Prescription drugs and prescribed over-the-counter drugs as recommended by the
U.S. Preventive Services Task Force (categories A and B) and, for women, by the
Health Resources and Services Administration are covered at one hundred percent
(100%) when filled at a network pharmacy;
H. Vaccines and administration as recommended
by the Advisory Committee on Immunization Practices of the Centers for Disease
Control and Prevention are covered at one hundred percent (100%) when filled at
a network pharmacy;
I. The
following are covered at one hundred percent (100%) when filled at a network
pharmacy:
(I) Prescribed preferred diabetic
test strips and lancets; and
(II)
One (1) preferred glucometer;
J. If any ingredient in a compound drug is
excluded by the plan, the compound will be denied; and
K. Drugs permitted by the Internal Revenue
Service (IRS) in Notice 2019-45 and selected by the plan are not subject to the
deductible when filled at a network pharmacy. Applicable coinsurance will
apply.
2. Non-network:
If a member chooses to use a nonnetwork pharmacy, s/he will be required to pay
the full cost of the prescription and then file a claim with the PBM. The PBM
will reimburse the cost of the drug based on the network discounted amount as
determined by the PBM, less the applicable deductible or coinsurance.
A. Preferred formulary generic drug: forty
percent (40%) coinsurance after deductible has been met for up to a thirty-one-
(31-) day supply for a generic drug on the formulary.
B. Preferred formulary brand drug: forty
percent (40%) coinsurance after deductible has been met for up to a thirty-one-
(31-) day supply for a brand drug on the formulary.
C. Non-preferred formulary drug and approved
excluded drug: fifty percent (50%) coinsurance after deductible has been met
for up to a thirty-one- (31-) day supply for a drug not on the
formulary.
D. Diabetic drug (as
designated as such by the PBM) coinsurance: fifty percent (50%) of the
applicable non-network coinsurance after deductible has been met.
(2) Step
Therapy-Step therapy requires that drug therapy for a medical condition begin
with the most cost-effective and safest drug therapy before moving to other,
more costly therapy, if necessary. The member is responsible for paying the
full price for the prescription drug unless the member's provider prescribes a
first-step drug. If the member's provider decides for medical reasons that the
member's treatment plan requires a different medication without attempting to
use the first-step drug, the provider may request a preauthorization from the
PBM. If the preauthorization is approved, the member is responsible for the
applicable copayment, which may be higher than the first-step drug. If the
requested preauthorization is not approved, then the member is responsible for
the full price of the drug.
(3)
Filing of Claims-Claims must be filed within twelve (12) months of filling the
prescription. A member may request a claim form from the plan or the PBM. In
order to file a claim, the member must-
(A)
Complete the claim form and follow its instructions;
(B) Attach a prescription receipt or label
with the claim form. Patient history printouts from the pharmacy are acceptable
but must be signed by the pharmacist. Cash register receipts are not acceptable
for any prescriptions except diabetic supplies; and
(C) A member must file a claim to receive
reimbursement of the cost of a prescription filled at a non-network pharmacy.
Non-network pharmacy claims are allowed at the network discounted amount as
determined by the PBM, less any applicable copayment, deductible, or
coinsurance. A member is responsible for any charge over the network discounted
price and the applicable copayment.
(4) Formulary. The formulary is updated on a
semi-annual basis, or when-
(A) A generic drug
becomes available to replace the brandname drug;
(B) A drug becomes available
over-the-counter. If this occurs, then the drug is no longer covered under the
pharmacy benefit unless otherwise specified; or
(C) A drug is determined to have a safety
issue by the United States Food and Drug Administration (FDA). If this occurs,
then the drug is no longer covered under the pharmacy benefit.
(5) Quantity Level Limits.
Quantities of some medications may be limited based on recommendations by the
FDA or credible scientific evidence published in peer-reviewed medical
literature.
Notes
*Original authority: 103.059, RSMo 1992.
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