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SISC CO-PAYMENT REFERENCE GUIDE
Medco manages your prescription drug benefit at the request of SISC. Your plan gives you
the option of getting your covered medications through Medco By Mail or at a participating
retail pharmacy.
The chart below provides a summary of your prescription drug benefit co-payments.
When you use a participating
When you use Medco By
Type of medication
retail pharmacy, you pay:
Mail, you pay:
$7 co-payment
$14 co-payment
$25 co-payment
$60 co-payment
*A generic drug will always be dispensed if one is available. If you purchase a brand-name drugwhen a generic alternative is available, you will pay the generic co-payment plus the difference incost between the brand and the generic, even if your doctor writes “dispense as written” (DAW) onthe prescription. For your short-term prescription needs, visit a participating retail pharmacy. When youpresent your member ID card, you will be charged a co-payment for your prescription. Formedication you take on an ongoing basis, using Medco By Mail offers you convenience andpotential cost savings. You can get more information about the Medco By Mail program bycalling 1 800 MEDCO-MAIL (1 800 633-2662). If you have Internet access, you can visit us online at www.medco.com. After registering,
you can access information about your benefits, as well as health and wellness resources.
You may also contact Member Services toll-free at 1 800 987-5241. Medco looks forward
to meeting all of your prescription benefit needs.
Medications that are not covered by your drug plan
Listed below are medications and medication categories that are not covered under your
SISC drug plan. The list may not reflect all noncovered drugs and may be subject to change.
To confirm whether a prescription drug you need to take is covered or to check the cost of a
medication, visit www.medco.com and click “Price a medication.” (If you’re a first-time visitor
to the site, please take a moment to register. You’ll need your member ID number and the
number from a recent prescription.) You can also get coverage and pricing information by
calling Medco Member Services toll-free at 1 800 987-5241.
Please note that this list may not be all-inclusive.
• Anti-wrinkle agents (Renova®, Retin-A®, and Avita® for patients aged 36 and over)• Experimental drugs• Fertility medications (Follistim®, Gonal-f ®, Clomid®, and Repronex®)• Influenza treatments (for example, Relenza® and Tamiflu®)• Medications labeled “Caution—limited by federal law to investigational use”• Over-the-counter medications (except Prilosec OTC®)• Pigmenting/depigmenting agents (hydroquinone, Eldopaque® and Eldoquin®)• Hair growth and hair removal agents (Propecia® and Vaniqa®)• Smoking cessation agents (Nicorette®, Zyban®, Chantix™, and all nicotine patches)• Vitamins (except prescription strengths of prenatal vitamins, hematinics, Rocaltrol® • Brand non-sedating antihistamines (e.g. Clarinex®, Clarinex-D®, Xyzal®) (See the reverse side for your plan’s co-payment reference guide.)

Source: http://academic.cuesta.edu/insurance/Documents/SISC/G22%207-25.pdf

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