Prescription Drug Benefit

Appropriate and cost-effective use of pharmaceutical therapies can be the key to a successful strategy for improving individual patient outcomes and containing overall healthcare costs. Through your EHP Prescription Drug Benefit, you have three options for filling your prescription medications. The three options described on the following pages include the Cleveland Clinic Pharmacies Prescription/Mail Order Benefit (includes Cleveland Clinic Pharmacies in Cleveland and Cleveland Clinic Weston Pharmacy), the CVS Caremark Retail Network Pharmacies, and the CVS Caremark Mail Service Program.

View and print the Cleveland Clinic EHP Total Care Drug Formulary Book by clicking here
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View and Print the Cleveland Clinic Employee Health Plan Member's Guide to Generic Drugs by clicking here
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Cleveland Clinic Pharmacies Prescription/Mail Order Benefit

EHP members will receive a lower percentage co-insurance for their prescriptions by using the Cleveland Clinic Pharmacies in Cleveland or Cleveland Clinic Weston Pharmacy. You may request up to a 90 day supply of medication and have access to a pharmacy hotline for questions and pharmacist consultation services. Note: By law, Cleveland Clinic Pharmacies must fill your prescription for the exact quantity of medication prescribed by your doctor, up to the 90 day plan limit. (30 days plus two refills does not equal one prescription written for 90 days.)

You may pick up your prescriptions at any of the locations listed below. If you live outside of any of these areas, you can have one of these locations mail your prescription(s) to your home.

In conjunction with the Employee Health Plan (EHP), the Cleveland Clinic Pharmacies provide a free mail order prescription service for EHP members and their dependents. The mail order service is efficient and convenient, with your prescription being shipped within 5 business days.

So, how can you get started? The grid below outlines the instructions for new prescriptions, obtaining refills and transferring prescriptions from your retail pharmacy. Should you have questions, contact the Cleveland Clinic Mail Order Pharmacy at 216-445-7363.

* NOTE: prescriptions from retail pharmacies are generally written for a 30 day supply. If a 90 day supply is requested, a new prescription written for a 90 day supply will be required from your physician.

Advantages of Utilizing the Cleveland Clinic Pharmacies Prescription/Mail Order Benefit
	Lower cost: You’ll pay less for prescription co-insurance — by an average of 20% to 25% less. Also, the deductible will be waived for generic prescriptions filled at these pharmacies.
	Convenience: You may request a 90 day supply of medications. Note: The prescription must be written for a 90 day supply.
	Peace of mind: You’ll have access to a toll-free hotline number for questions and pharmacist consultation services during regular business hours.
Filling Prescriptions
	Your doctor can call in the prescription.
	You can call to request refills.
	You or your doctor can mail in the prescription.
	You can order refills online via the Web site at clevelandclinic.org/pharmacy
Picking up Prescriptions
	You may pick it up directly from the pharmacy where you dropped it off.
	You may have it mailed to your home within five business days at no cost.
Options for Members Who Don’t Live or Work Near a Cleveland Clinic Pharmacy
Employees have the option of either mailing their original prescriptions or having their doctor call in a prescription to the Cleveland Clinic Pharmacies in Cleveland or the Cleveland Clinic Weston Pharmacy. Your prescription will then be mailed to you at no additional charge. You can then either call the desired pharmacy or request refills via the Web site at clevelandclinic.org/pharmacy. Contact your pharmacist for instructions on how to gain access to your pharmacy profile via this Web site.
CVS Caremark Retail Network Pharmacies
For the convenience of picking up prescriptions at your neighborhood pharmacy, EHP members can take advantage of this option. See the Prescription Drug Benefit grid on page 48 of your SPD for major chains in the retail network. When using the CVS Caremark Retail Network, employee co-insurance is higher than under the Cleveland Clinic Pharmacies Prescription/Mail Order Benefit. Only a 30 day supply of medications can be obtained through the retail pharmacies. CVS Caremark offers over 55,000 participating retail pharmacies in their national pharmacy network, which are listed on CVS Caremark’s Web site at caremark.com.
CVS Caremark Mail Service Program
New Prescriptions
CVS Caremark’s Mail Service Program provides a way for you to order up to a 90 day supply of maintenance or long-term medication for direct delivery to your home. Follow this easy step-by-step ordering procedure:
1.	For new maintenance medications, ask your doctor to write two prescriptions:
		One, for up to a 90 day* supply plus refills, to be ordered through the Mail Service Program; and
		The other, to be filled immediately at a CVS Caremark participating retail pharmacy for use until you receive your prescription from the Mail Service Program. *Note: By law, CVS Caremark must fill your prescription for the exact quantity of medication prescribed by your doctor, up to the 90 day plan limit. (30 days plus two refills does not equal one prescription written for 90 days.)
2.	Complete a CVS Caremark Mail Service Order Form and send it to CVS Caremark, along with your original prescription(s) and the appropriate payment for each prescription. Be sure to include your original prescription, not a photocopy. Forms are available on CVS Caremark’s Web site at caremark.com.
		You can expect to receive your prescription approximately 14 calendar days after CVS Caremark receives your order.
		You will receive a new Mail Service Order Form and pre-addressed envelope with each shipment.
Mail Service Refills
Once you have processed a prescription through CVS Caremark, you can obtain refills using the Internet, phone or mail. Please order your prescription three weeks in advance of your current prescription running out. Suggested refill dates will be included on the prescription label you receive from CVS Caremark. You will receive specific instructions related to refills from CVS Caremark.
View and print the CVS Caremark Mail Order Form (2 pages) by clicking the link below (Adobe Acrobat Reader is required)
Prescription Drug Benefit Guidelines
Prescription Drug Benefit — Deductible
The Prescription Drug Benefit has an annual deductible of $100 individual/$300 family. This means that, with the exception of families with four or more EHP members, each family member must meet the $100 individual deductible to satisfy the $300 family deductible. For families with four or more EHP members, after two family members meet the $100 individual deductible, two other family members may combine their individual deductibles (e.g., $50 each) for the remaining $100 to satisfy the $300 family deductible. Note: Prescriptions filled at a Cleveland Clinic Pharmacy for generic medications are not subject to the deductible. Members will still pay the deductible when they purchase all brand name and generic medications at other pharmacies.
Deductible and Out-Of-Pocket (OOP) Maximum
Not all pharmacy charges apply toward the deductible and out-of-pocket (OOP) maximum expenses. The total charges for medications not covered by the plan (e.g., Viagra, Levitra, weight control products, cosmetic agents) do not apply to either the deductible or out-of-pocket maximum. In addition, the Dispense as Written Penalty (DAW) that applies to some brand name medications does not apply to the deductible or OOP. If a generic version of the prescribed brand medication exists, the Prescription Drug Benefit will reimburse only up to the price of the generic version. If you choose to use the brand name, you are required to pay the price difference between the generic and the brand medication. That difference does not apply to the deductible or the OOP (see Generic Medication Policy).
Generic Medication Policy
Cleveland Clinic supports and encourages the use of FDA-approved generic drugs that are both chemically and therapeutically equivalent to manufacturer’s brand name products. Generically equivalent products are safe and effective treatments that offer savings as alternatives to brand name products. If a member or physician requests the brand name drug be dispensed when a generic is available, the participant will be required to pay their generic co-insurance AND the cost difference between the brand name drug price and the generic drug price.
Prior Authorization
Prior authorization is necessary for coverage of certain medications. These medications are listed in your Cleveland Clinic EHP Drug Formulary Book. The medications on the list may change during the year due to new drugs being approved by the FDA or as new indications are established for previously approved drugs. A Prior Authorization/Formulary Exception Form (see below) must be completed or sufficient documentation must be submitted before a case will be reviewed. All requests must meet the clinical criteria approved by the Pharmacy and Therapeutics (P&T) Committee before approval is granted. In some cases, approvals will be given a limited authorization date. If a limited authorization is given, both the member and the physician will receive documentation on when this authorization will expire. Most requests will be processed within 1-2 business days from the time of receipt. A response will be faxed to the requesting physician, and the member will be informed of the request and the decision via mail.
Formulary Failure Review Process
If it is determined that an EHP member is not responding to drugs available on the Formulary, your physician may request a review for preferred coverage of a Non-Formulary drug. To start the review process, your physician should call the Cleveland Clinic EHP Pharmacy Management Department located at CHN at 216-986-1050 or toll-free at 1-888-246-6648 and request a Prior Authorization/Formulary Exception Form or you may provide your physician with the form yourself (located below). All requests must be in writing and signed by the prescribing physician. If a Non-Formulary drug is approved, the member will be responsible for a 30% co-insurance* with no monthly maximum out-of-pocket. The co-insurance amount will be applied to the yearly maximum out-of-pocket. In most cases, approvals will be given an unlimited authorization date, so that you will not be required to resubmit a request every year. Most requests will be processed within 1-2 business days from the time of receipt. A response will be faxed to the requesting physician, and we will also inform the member of the request and the decision via mail. *Lower co-insurance will be assessed from the date of authorization. No refunds will be made for previously purchased prescriptions. View and print the Prior Authorization/Formulary Exception Form by clicking here. (Adobe Acrobat Reader is required)
Benefits and Coverage Clarification
Compounded Prescriptions
A customized medication prepared by a pharmacist according to a doctor’s specifications is considered a compounded prescription. These prescriptions are considered non-preferred and have a charge of 45% at a Cleveland Clinic Pharmacy or 50% at all other locations.
IUD and Depo-Provera Guidelines
IUD insertions are a form of birth control; and in most cases, Depo-Provera is used as a birth control method. IUD insertions are a form of birth control and therefore will have a $50 co-insurance charge. If Depo-Provera is used as a birth control method, the member will be charged the Pharmacy Plan copayment of $15 per injection when supplied by a doctor’s office. Standard co-payment rates are charged if Depo-Provera is purchased at a pharmacy.
Oral Medications for Onychomycosis (Nail Fungus)

Most drugs that are available without a prescription are not covered under the Prescription Drug Benefit. When a drug is available in the identical strength, dosage form and is approved for the same indications, the prescription drug is usually not covered by the plan. Providers should recommend the equivalent over-the-counter (OTC) product to the patient.

The exception is Prilosec OTC, which the EHP covers under the Prescription Drug Benefit to decrease the member's out-of-pocket expenses. A doctor must write a prescription for Prilosec OTC for it to be covered by the Prescription Drug Benefit.

Pharmacy Management Programs

Quantity level limits are applied to medications for various reasons. For example, to prevent medication misuse or abuse, to promote adherence to an appropriate course of therapy for reasons of efficacy and safety, and to prevent the stockpiling of medication. Below is a list of medications that have quantity level limits. The EHP will continue to monitor drug utilization to possibly expand quantity level limits for other medications.

Actonel 35mg - 4 tablets per 28 days
Actos 15mg - 1 tablet per day
Ambien 5mg - 1 tablet per day
Amerge tablets - 9 tablets per 30 days
Anzemet - 6 tablets per 30 days
Axert tablets - 12 tablets per 30 days
Boniva 150mg - 1 tablet per 30 days
Cymbalta 30mg - 1 capsule per day
Detrol LA 2mg - 1 capsule per day
Effexor XR 37.5mg - 1 capsule per day
Effexor XR 75mg - 1 capsule per day
Emcyt - 30 day supply; limit based on instructions for use
Fosamax 35mg - 4 tablets per 28 days
Fosamax 70mg - 4 tablets per 28 days
Frova tablets - 9 tablets per 30 days
Gleevec - 30 day supply; limit based on instructions for use
Hexalen - 30 day supply; limit based on instructions for use
Hycamtin - 30 day supply; limit based on instructions for use
Imitrex tablets - 12 tablets per 30 days
Imitrex nasal spray - 12 sprays per 30 days
Imitrex injection - 4 kits per 30 days
Iressa - 30 day supply; limit based on instructions for use
Kytril - 12 tablets per 30 days
Maxalt tablets - 12 tablets per 30 days
Nexavar - 30 day supply; limit based on instructions for use
Relpax tablets - 12 tablets per 30 days
Revlimid - 30 day supply; limit based on instructions for use
Sprycel - 30 day supply; limit based on instructions for use
Sutent - 30 day supply; limit based on instructions for use
Tabloid - 30 day supply; limit based on instructions for use
Tarceva - 30 day supply; limit based on instructions for use
Targretin - 30 day supply; limit based on instructions for use
Tasigna - 30 day supply; limit based on instructions for use
Teslac - 30 day supply; limit based on instructions for use
Toradol 10mg - 20 tablets per 30 days
Treximet 85-500 - 12 tablets per 30 days
Tykerb - 30 day supply; limit based on instructions for use
Valtrex 1000mg - 30 tablets per 365 days
Valtrex 500mg - 10 tablets per 30 days
Various acetaminophen containing products - 4 grams a day
Wellbutrin XL 150mg - 1 tablet per day
Zofran - 18 tablets per 30 days
Zolinza - 30 day supply; limit based on instructions for use
Zomig nasal spray - 12 sprays per 30 days
Zomig tablets - 12 tablets per 30 days

Specialty Drug Benefit

In addition to the comprehensive prescription benefit management programs, CVS Caremark offers specialized pharmaceutical services for individuals with chronic or genetic disorders, and disease management programs for individuals with complex conditions. By combining proven managed care strategies with a strong clinical orientation and sophisticated information systems, the EHP Specialty Drug Program enables plan members to enhance their clinical outcomes and gain control over their out-of-pocket (OOP) expenses.

Members will be responsible for their co-payment for all drugs that are determined to be self-administrable by the patient. Self-administrable medications are defined as medications that are typically administered subcutaneously (SC) and have patient instruction for use in the package insert (PI). Some intramuscular injections are also considered self-administrable due to frequency of injection and PI instructions for the patient on how to self-administer the drug. A co-payment applies at all locations where the drug can be obtained. If a self-administrable drug is administered in a doctor’s office, the member will be responsible for the office co-payment as well as the drug co-payment. If administered in the physician's office, the co-pay is not applied to the pharmacy deductible or out-of-pocket maximum. Medications that are not self-administered are covered under the medical benefit.

The Cleveland Clinic EHP considers the following categories of drugs as specialty drugs: