In This Section:

• 5.1 Generic Equivalent Requirement
• 5.2 Filling a Prescription
• 5.3 Network Retail Pharmacy Co-Payments
• 5.4 Citizens Rx Home Delivery (Mail Order)
• 5.5 Non-Network Pharmacy Reimbursements
• 5.6 Covered Benefits
• 5.7 Limitations
• 5.8 Exclusions
• 5.9 Partial List of California Network Pharmacy Chains

The following Retiree Health Plan Participants are eligible to receive prescription drug coverage through the Mandatory Generic Prescription Drug Plan:

• Participants under age 65 and covered under the UnitedHealthcare HMO plan; and
• Grandfathered Medicare Supplemental Plan Participants

Participants age 65 and over that are covered under the Kaiser Permanente or UnitedHealthcare HMO plans receive prescription drug benefits through their HMO provider, and the Out-of-Area Plan Participants are covered through UnitedHealthcare.

5.1 Generic Equivalent Requirement

Under the Mandatory Generic Prescription Drug Plan, you must fill a prescription with a generic equivalent, whenever it is available.

If you or your doctor requests a brand name drug instead of a generic equivalent, you will be charged the difference in cost between the brand name drug and the generic equivalent, plus the applicable co-payment.

5.2 Filling a Prescription

The Plan allows up to a 30-day supply of medication, or a 100-day supply for maintenance medication.

You may fill your prescription through:

• a retail pharmacy; or
• Citizens Rx Home Delivery service.

If you fill your prescription at a network pharmacy or through Citizens Rx Home Delivery, the applicable co-payment will apply.

If you fill your prescription at a non-network pharmacy, you will pay the full cost of the medication at the time of purchase. See Article 5.5: Non-Network Pharmacy Reimbursements beginning on page 26 for more information.

5.3 Network Retail Pharmacy Co-Payments

A listing of the California network pharmacy chains is included in Article 5.9: Partial List of California Network Pharmacy Chains on page 30.

5.4 Citizens Rx Home Delivery (Mail Order)

The Citizens Rx Home Delivery service is an easy and convenient way for you to fill your prescriptions for maintenance medication (up to a 100-day supply). Consider:

• You submit your prescription using the pre-printed envelope sent to you by Citizens Rx.
• Your co-payment can be paid by check, money order, or credit card. Eligible participants can also use funds from their Health Reimbursement Arrangement account to pay the co-payment (see page 31 for more information).
• You are not required to pay mailing expenses for standard deliveries.
• Once your order is received, your medication will be delivered to your home within seven (7) working days.
• For information on ordering refills online go to (www.citizensrx.com) or by calling (888) 545-1120.

The Citizens Rx Home Delivery service is only available for maintenance medications.

5.4.1 Citizens Rx Home Delivery Co-Payments

5.5 Non-Network Pharmacy Reimbursements

You are encouraged to use network pharmacies or the Citizens Rx Home Delivery service to fill your prescriptions. However, the Retiree Health Plan will reimburse you a limited amount for a prescription filled at a non-network pharmacy. This policy is intended for emergency purposes (e.g. traveling away from home). You may obtain up to a 30-day supply.

Non-network pharmacy claim forms are available from the Administrative Office or on www.scibew-neca.org. You will fill out one portion of the claim form. The pharmacy must fill out the rest of the form.

Completed claim forms should be mailed to:

Citizens Rx
1144 Lake Street
Oak Park, IL 60301
4th Floor

Claims will generally be processed within 30 days from the date the claim is received. You will be reimbursed based on a limited formula, less a $5 co-payment for each generic prescription and a $15 co-payment for each brand name prescription.

You must file your claim within 15 months of the date the prescription was filled.

5.6 Covered Benefits

The Mandatory Generic Prescription Drug Plan covers the following services and materials:

1. Federal legend drugs: Any medicinal substance which bears the legend, "Caution: Federal law prohibits dispensing without a prescription;"
2. State-restricted drugs: Any medicinal substance, which may be dispensed by prescription only according to state law;
3. Federal legend oral contraceptives and birth control pills;
4. Contraceptive products, including, but not limited to diaphragms, cervical caps, Depo-Provera� injections and Ortho-Evra� patches;
5. Inhaler extender devices and bags (e.g. Aerochamber�, Aerochamber� with mask, Easivent�, Inspirsease�, EZ-Spacer�, Optichamber�, Optihaler�, Ellipse�);
6. Anaphylaxis prevention kits, including, but not limited to, Epi-Pen�, Epi-Pen Jr.�, Ana-Kits�, Ana-Kit Jr.�, Glucagon�, Glucagon Emergency Kit�, and Ana-Guard�;
7. Compounds with at least one federal legend or state-restricted ingredient;
8. Normal saline for inhalation and irrigation;
9. Prescription prenatal vitamins; and
10. Injectables (see also Exclusions for exceptions).

The following non-prescription items are also covered when prescribed in writing by a physician and dispensed by a licensed pharmacist:

1. Insulin, insulin syringes and needles;
2. Blood glucose test strips;
3. Urine glucose test strips;
4. Sterile lancets; and
5. Novolin� pen, Humulin� pen, pre-filled pens, pen needles and cartridges.

5.7 Limitations

The following items are a covered benefit subject to the limitations as stated below:

1. Drugs prescribed to treat erectile dysfunction (including, but not limited to, Viagra�, Cialis� and Levitra�) are covered for a maximum of eight (8) pills for a 30-day supply.
2. Smoking deterrents, when prescribed in writing by a physician, subject to the following limitations:
   1. Up to a 90-day supply per year; and
   2. No more than a 180-day supply per lifetime.
   This limitation applies to smoking deterrents received from both a retail pharmacy and the Citizens Rx Home Delivery service. It is recommended you discuss a treatment Plan with your physician. There are many products to assist you in smoking cessation, including:
   1. Nicotine patches;
   2. Nicotine gum;
   3. Nicotine nasal spray (prescription required);
   4. Nicotine inhalers (prescription required);
   5. Nicotine lozenges; and
   6. Zyban� (Bupropion) (prescription required).
3. Morning After pills and kits (i.e. Preven�, Plan B�) — limited to two (2) total per person per 365 days.

5.8 Exclusions

The following items are not covered:

4. Drugs for which no charges are made, of which are provided under any Workers' Compensation or similar benefit or for which reimbursement is provided by any federal, state, or other governmental agency;
5. Medications available without a prescription (over-the-counter) or prescription medications for which there is a non-prescription equivalent available, even if ordered by a physician via a prescription, except as listed under Covered Benefits;
6. Infertility drugs;
7. Anorexiants/appetite suppression weight loss drugs;
8. Medications for the treatment of sexual dysfunction (except drugs to treat erectile dysfunction, such as Viagra�, Cialis� and Levitra�);
9. Medications to be taken or administered to the eligible member while he is a patient in a hospital, nursing home (skilled nursing care only), rest home, sanitarium, etc;
10. Medications used for cosmetic purposes (e.g. Renova�, Rogaine�, Vaniqa�, Penlac�, pigmenting and depigmenting agents);
11. Medical devices, therapeutic devices or appliances including hypodermic needle syringes, (except insulin syringes) support garments and other non-medicinal substances (unless listed as covered);
12. Drugs or medicines purchased and received prior to the member's effective date or subsequent to the member's termination;
13. Drugs or medicines purchased or administered to the member by a prescriber or prescriber's staff. For example, drugs administered, injected, or dispensed by a physician. However, injectables obtained at a pharmacy will be covered;
14. Medications prescribed for experimental or non-FDA approved indications unless prescribed in a manner consistent with a specific indication in Drug Information for the Health Care Professional, published by the United States Pharmacopoeial Convention, or in the American Hospital Formulary Services edition of Drug Information; medications limited to investigational use by law;
15. All homeopathic medications;
16. Unit dose drugs (unless only available as unit dose);
17. Vitamins (other than prescription prenatal vitamins);
18. Dental-related products (e.g. prescription oral and topical fluoride, Peridex�, Atridox�, Periostat�);
19. Prescription drug claims submitted after 15 months from the date the prescription was filled;
20. Biological sera;
21. Blood and blood plasma;

5.9 Partial List of California Network Pharmacy Chains

For an up-to-date list of nationwide pharmacies, go to www.citizensrx.com or call (888) 545-1120.

The following is a sample list of network pharmacies in California as of the date of this printing:

• Albertsons
• Costco
• CVS (including Target Pharmacy and Longs)
• Horton and Converse
• K-Mart Pharmacies
• Medicine Shoppe
• Pavilions Pharmacies
• Raley's Super Stores
• Ralphs
• Rite Aid
• Safeway Pharmacy
• Save Mart Supermarkets
• Sav-On Pharmacy Drugs
• Shopko Stores
• Vons/Pavilions Pharmacies
• Walgreens
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