Preventive care rx flier (c1113).pdf

escription Drugs
The use of prescribed medications, both prescription and over-the-counter (OTC), can be an effective way
for members to maintain good health. As part of healthcare reform, the U.S. government has identified the
following types of medications as important for preventing future illness.
To receive 100-percent coverage for these medications, members must get a prescription from their doctor and present it atthe pharmacy. Even if the medication is available OTC without a prescription, a prescription must be presented to thepharmacy for it to be covered at no out-of-pocket cost to the member. If a member uses a non-network retail pharmacy tofill a prescription for one of these medications, he or she may be subject to non-network penalties, if applicable.
Health insurance carriers (or health plans) are required by the Patient Protection and Affordable Care Act to fully coverthe following preventive care medications: Drug Type
Medication Examples
Coverage Rules 1
aspirin, Bayer, children’s aspirin Applies to male members ages 45 – 79 years and female members ages 55 – 79 years Epiflur, Luride, ReNaf, sodium fluoride Ed-In-Sol, Fer-Gen-Sol, ferrous sulfate, Siderol Chantix, Nicoderm CQ, nicotine gum, Zyban 90-day supply per rolling 365-day period (most brands/generics);180-day supply per rolling 365-day period (Chantix) hormonal contraceptives, diaphragms, other 1. Prescription benefit plan coverages and exclusions may apply outside of the coverage rules described.
2. Applies to non-grandfathered plans only, beginning with plan years on or after August 1, 2012. Please see additional information on the back of this flier.

Non-Grandfathered Plans
For plan years beginning on or after September 23, 2010, non-grandfathered group health plans must cover these
preventive care medications (contraceptive coverage effective with plan years on or after August 1, 2012). If a member
presents a prescription at an in-network retail pharmacy or the Express Scripts Home Delivery pharmacy, he or she cannot
be charged a copay, coinsurance or deductible, or they must be reimbursed 100 percent by their plan.
Grandfathered Plans
We also recommend grandfathered plans consider covering these preventive medications, which may help reduce overall
healthcare costs.
If you have questions about these recommended preventive medications, contact your Medical Mutual, Carolina CarePlan or Business Distribution Solutions representative. Please Note: Medical Mutual makes this information available as a courtesy to our groups and members with prescription drug benefits through Express
Scripts (formerly Medco Health Solutions, Inc.), our pharmacy benefits manager.
2013 Medical Mutual of Ohio
Contraceptive Coverage
For plan years beginning on and after August 1, 2012, non-grandfathered group health plans and health insurance issuers
must provide coverage of women’s preventive health services with no cost sharing to the member. This requirement
includes all Food and Drug Administration (FDA)-approved contraceptive methods.
In addition, the rules governing coverage of general preventive services, which allow plans to use reasonable medicalmanagement to help define the nature of the covered services, also apply to women’s preventive health services. Plans havethe flexibility to control costs and promote efficient delivery of care. For example, a plan might ask employees to sharethe cost of a brand-name drug if a generic version is available that is just as effective and safe.
For our standard plan offerings with prescription drug benefits administered through our relationship with Express Scripts,our pharmacy benefit management (PBM) partner,1 Medical Mutual will administer the following contraceptive drug typesat no cost sharing to members: Brand-name drugs that do not have a generic equivalent (brand-name contraceptive drugs that have a genericequivalent will be subject to the member’s applicable copay, coinsurance and/or deductible) Over-the-counter contraceptive products if the member has a valid prescription 2, 3 The range of prescription contraceptives includes diaphragms and hormonal contraceptives like oral birth controlpills, birth control patches, vaginal rings, injectable contraceptives and intrauterine devices (IUDs). Please note: Notall of these prescription contraceptives are available at a retail network pharmacy or mail-order pharmacy, and mustbe obtained through a provider.
Other prescription drug benefit rules, such as mail-order incentive programs, still apply; therefore, a member may havefinancial penalties if she continues to fill her contraceptive prescriptions at a retail network pharmacy when a mail-orderincentive program is in place. However, coverage management rules will not apply for contraceptives.
1. If a group offers prescription drug benefits through a PBM other than our relationship with Express Scripts, that PBM may adopt different guidelines.
2. Over-the-counter contraceptives include female condoms (not male condoms), sponges, spermicides and the Plan B (morning after) pill. A member must get a prescription for these over-the-counter contraceptives to receive 100-percent coverage.
3. Due to continuous drug changes in quantity, strength and coding, a specific list of covered drugs is not available. For questions about a specific drug or product, please call Customer Service at the number on your Medical Mutual ID card, or Express Scripts Member Services at (800) 417-1961.


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