MaxorPlus: Wichita Public Schools USD259 Coverage Period: 01/01/ /31/2016 Summary of Drug Coverage: What drugs this Plan Covers & What it Costs

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1 This is only a summary. If you want more detail about your coverage and costs, you can get additional information at or by calling Prescription Benefit Important Questions What are my costs for prescription medications? More information about prescription drug coverage is available at Answers Why this Matters: Limitations & Exceptions Your cost is determined based on the type of drug and the day supply obtained. See below. Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty Retail Pharmacy Mail Order Pharmacy N/A *Drugs may have restricted quantities or authorization requirements. All charges are subject to individual $1000 deductible and/or $2000 family deductible. Limited to a 30 day supply; Limited to Maxor Specialty Pharmacy after one fill at retail Contraceptives $0 $0 Generics and single source brands. Devices and Implants are excluded under prescription benefits. Diabetic Preferred Insulin and Supplies 1 of 6

2 Prescription Benefit Important Questions Dillons Pharmacy Diabetic Program Dillons Pharmacy Diabetic Program Answers Why this Matters: Limitations & Exceptions Generic Blood Pressure Medications Generic Cholesterol Medications Diabetic Preferred Medications N/A N/A Member must be enrolled in PPO Plan. Generic Oral Diabetic Medications N/A N/A Member must be enrolled in PPO Plan. Can I get a list of drugs showing generic, preferred or non-preferred status? Are there drugs that are not covered? Is there a deductible on prescriptions? Is there an out of pocket limit on my expenses? Is there an overall annual limit on what the plan pays? No $1000 individual/$2000 family No A formulary is a list of drugs showing the generic, preferred brand, and non preferred brand status, which determines copay amounts. MaxorPlus Preferred Drug Formulary is located at Certain drugs may not be covered under the Rx drug plan. Drugs may have certain quantity limitations or prior authorization requirements. See additional information on Page 3 Excluded Drugs and other Limitations or restrictions, or the at A deductible would require you to pay the full cost of a prescription until that amount is met, at which time, the copayments above take effect. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. An annual plan limit is the total amount the health plan will pay for specific services such as prescription drugs per benefit year. This limit helps you plan for health care expenses. 2 of 6

3 Prescription Benefit Important Questions Does this plan use a network of pharmacies? Do I have to use Mail Order to obtain a 90 day supply? Answers Why this Matters: Limitations & Exceptions. See or call for a list of participating providers. The Rx plan requires you to use a network pharmacy. Prescriptions purchased at non-network pharmacies are covered only in emergency situations. You will need to pay of the cost of the drug, then submit a paper claim along with the receipt for reimbursement. The paper claim form can be found at You must use Maxor Mail Order for 90 day supply home delivery, which saves you time at the pharmacy as well as copays (3 month supply for 2 copays). 30 day supplies are available at local retail pharmacies. To contact Maxor Mail Order, please call Do I have to use generic drugs only? No You are not required to use only generic drugs. 3 of 6

4 Included Services and Types of Medication: Drugs Your Plan Covers Accutane Aerochambers Anaphylactic Kits Aspirin oral Rx and OTC Compounded medications of which at least one ingredient is a legend drug DESI Drugs Diabetic supplies Insulin pens/needles, test strips/tape/tabs, lancets Drugs for ADD/ADHD/Nacolepsy Drugs for Sexual Dysfunction Flouride supplements Rx Oral Only Folic acid Rx and OTC Glucometers Growth hormones Immunizations/Vaccines/Toxoids Injections Self-administered (not listed under exclusions) Insulin Iron Supplements Rx and OTC Legend drugs, except for drugs listed as exclusions Medical supplies needed to infuse covered medications Nasal Steroids Rx and OTC Non-sedating Antihistamines Rx and OTC PPI Rx and OTC Tobacco deterrents Rx and OTC State Restricted Drugs (i.e., DEA Schedule V) Topical tretinoins Vitamins Rx Prenatal, Rx pediatric and Vitamin D OTC Contraceptives Generic oral, injectable and patches - $0 copay Single source brands in classes that do not have a generic alternative - $0 copay Brands with generics available in route class (orals, injectables, patches) will be at regular copays *This is not intended to be a complete list. For additional information on covered prescription drug benefits please refer to Immunications/Vaccines/Toxoids - $0 copay Hepatitis A vaccine Hepatitis B vaccine Influenza Vaccine Measles Vaccine Mumps Vaccine Polio Vaccine Human Papillomavirus Vaccine Rabies Vaccine Rubella Vaccine Varicella Vaccine Haemophilus Vaccine Meningococcal Vaccine Tetanus Toxoid Diphtheria Toxoid Pertussis Toxoid Pneumococcal Rotavirus Zostavex And combination products of these Vaccines or Toxoids Preventive Medications - $0 copay Aspirin for patients 45 and older Folic acid for women up to the age of 55 Iron supplements up to the age of 1 Fluoride supplements up to the age of 6 Tobacco deterrents Vitamin D OTC for ages 65 and older 4 of 6

5 Excluded Services & Other Limitations or Restrictions: Drugs Your Plan Does NOT Cover Agents for weight loss Anabolic steroids Allergy serum/extracts Anti-sera/immune globulins Anti-wrinkle agents (ex. Renova) Blood, blood factors, blood plasma, or biological sera Depigmenting agents (ex. Hydroxyquinone) Devices, appliances, or supplies, including support garments & non-medicinal substances Drugs indicated for cosmetic uses Fertility agents all (oral and injectable) Hair growth stimulants Homeopathic/natural legend products Non-legend drugs (OTC s), except as listed above Nutritional supplements Syringes/needles, other than insulin type Vitamins, except RX Prenatal, Rx pediatric, and Vitamin D OTC Cosmetic hair removal products (ex. Vaniqa) Injectables office administered Dental products for periodontal disease Medical Supplies Other restrictions 90 day supply is limited to Maxor Mail Order Pharmacy Specialty medications are restricted to be filled at Maxor Specialty Pharmacy after one fill at retail. Drugs with special quantity limits C2 medications cannot be filled through Maxor Mail Order Pharmacy; these medications may be filled for a 30-day supply at a local retail pharmacy. See MaxorPlus standard Quantity Limit list at *list subject to change Tobacco deterrents- Limited to 2-12 week cycles/year Depo Provera Contraceptive- 90 day supply allowed at retail Estring-- 90 day supply allowed at retail Seasonique/Seasonale- 91 day supply allowed at retail 5 of 6

6 Drugs requiring prior authorization See MaxorPlus standard PA list* at *list subject to change Breast Cancer Preventative Abilify- brand Brand narcotic medications Brand topical antifungals Colcrys Combination inhalers Cuvposa Epaned Evzio Fulyzag Fycompa Giazo Gralise Horizant Jentadueto Kapvay Kazano Nymalize Performist Rescula Rilutek Savella Seroquel XR Striverdi Respimat Suboxone, Bunavil, Zubsolv Tekamlo Tekruna/Tekturna HCT Testosterone products Topical immunomodulator (i.e. Elidel, Protopic) Zioptan Zontivity Revision Log: 02/08/2016: Summary of Drug Benefits 6 of 6