Prescription Drug Benefits under the
University of Arkansas Prescription Drug Program

PharmaCare is the pharmacy benefit manager for the plan.

Summary of Benefits

Retail Day Supply Limitations:

Up to 90-day supply
*One retail co-pay applies per each 30-day supply purchased

Mail Order Day Supply Limitations:

Up to 90-day supply on maintenance
*One retail co-pay applies for each 30-day supply purchased

Standard Co-pay Amounts:

Retail (30-day supply)			Mail Order (90-day supply)
Generic (Tier 1)	$10.00		Generic (Tier 1)	$30.00
Formulary Brand (Tier 2)	$30.00		Formulary Brand (Tier 2)	$90.00
Non-Formulary Brand (Tier 3)	$50.00		Non-Formulary Brand (Tier 3)	$150.00

*CO-PAYMENT EXAMPLE: Formulary Brand drug purchased for 30-day supply = $30. For 60-day supply = $60. For 90-day supply = $90. This stepped co-pay applies to both mail and retail purchases of Generic, Formulary Brand and Non-Formulary Brands.

Mail Order Pharmacy:

PharmaCare Direct

Formulary Type:

3-tier Preferred Drug List

Dependent Age Limitations:

Dependents covered up to their 19th birthday. Dependents who are full-time students are covered up to their 25th birthday.

Prescription Drug Card Produced By:

PharmaCare (2 cards issued to primary member, additional cards can be requested online at www.pharmacare.com/members or by contacting PharmaCare Customer Service at 1-800-375-2596).

Refill Too Soon Restrictions:

Member must use 50% of medicine before refill permitted (60% if refill through mail order).

Paper Claim Reimbursement / Direct Member Reimbursement (DMR)

If a member fails to use prescription drug card at a retail pharmacy and submits a paper claim to PharmaCare for reimbursement, the claim will be paid at the same rate the pharmacy would have been paid, less the applicable copayment. There is also a $1.50 processing fee withheld from member reimbursement. DMR form available at http://www.pharmacare.com/members.

Pharmacy Network:

Full pharmacy network. Most pharmacies in Arkansas are included. List available at http://www.pharmacare.com/members.

Compounded Drug Reimbursement Policy

It is the policy of the University of Arkansas to place all compounded drugs at third tier ($50.00 co-pay) under the prescription drug program. A compounded drug is considered to be any drug that is combined with another drug outside of the manufacture’s setting. This policy includes the compounding of one or more generic drugs.

Brand Drug Status When Generic is Available

It is the policy of the University of Arkansas to place brand name drugs to third tier ($50) when its generic equivalent becomes available on the market. Moreover, if the member chooses the brand product over the generic when available, there may be a product penalty applied in addition to the first tier ($10) co-pay.

Please note that the Preferred Drug List is not intended to be inclusive or exclusive of all drugs in the market, but rather the more commonly used drugs. Be sure to verify coverage per plan programs and limitations. You may call PharmaCare Customer Service at 1-800-375-2596 or log in as a member at http://www.pharmacare.com/members

Covered Prescriptions

Covered drugs include the following.

(QL) = Quantity Limits (ST) = Step Therapy

Insulin Diabetic Supplies* (QL) Blood Glucose Monitor** Oral Contraceptives Nuvaring and Contraceptive Patches Glucagon Most Injectable Medications DEA Schedule V

Legend Vitamins, Pediatric Vitamins Pre-Natal Vitamins Primary HIV Treatments (QL) Compounds (QL) Smoking Cessation Acne Medications (QL) Retinoid Acne Products (QL) Sedatives/Hypnotics (QL) Migraine Therapies

Allergic Emergency Injectables (ST) Singulair (ST) Proton Pump Inhibitors (Ulcer meds) (ST) COX2 Inhibitors (Celebrex) (ST) ARBs (Hypertension) (ST) Ranexa (QL) Ultram ER (QL) Emsam Patch (QL) Actiq/Fentora

* NOTE: Diabetic supplies (Test Strips, Lancets, Alcohol Swabs, Insulin Needles/Syringes) are $0 when purchased with a physician’s prescription.

**NOTE: Blood Glucose Monitors are available at no charge to member by calling Lifescan at 1-888-427-8335.

PRIOR AUTHORIZATION REQUIRED (PA)

*Other medications not listed below may also require prior authorization.

Contact PharmaCare Customer Service at 1-800-375-2596 with questions on coverage and to begin prior authorization process.

Growth Hormones Hemophilia medications Erectile Dysfunction agents (will have limits w/ PA) Forteo Lamisil and Sporanox (oral antifungals)

Gleevec Xolair (Asthma) Antineoplastics Osteoporosis Injectables Nutritional Supplements for PKU Injectables

Nexavar Revlimid Botox Sutent Orencia

IMPORTANT INFORMATION ON THE PRIOR AUTHORIZATION PROCESS:

PharmaCare will provide the necessary paperwork to the prescribing physician for medications that require prior authorization. Member or prescribing physician must contact PharmaCare Customer Service at 1-800-375-2596 to begin the prior authorization process. Prescriptions listed as excluded (list available under the “Prescription Plan Exclusions” sheet at www.pharmacare.com/members will not be authorized under any circumstances. Authorizations for changes to copays will not be permitted under any circumstances. In the event a request for prior authorization is denied, members are to contact PharmaCare at 1-800-375-2596 if they wish to make an appeal.

EXCLUSIONS:

This is a categorically excluded list, i.e. broad categories are listed. To see if a particular medication is considered a plan exclusion, you may call PharmaCare Customer Service at 1-800-375-2596 or log in as a member at www.pharmacare.com/members and utilize the Co-Pay Counselor.

*Diaphragms, IUDs, and Misc. Contraceptives Emergency Contraceptives Fertility Medications *Implantable Contraceptives Cosmetic Alteration Drugs Hair Loss Weight Loss Dental Products Topical Dental Fluorides Immunizations Misc. Medical Supplies Misc. Syringes

Infant Formulas or Liquid Nutritional Supplements Over the Counter (OTC)     Medications Cough/Cold/Allergy     Medications w/ OTC     Equivalents Cream /Ointment/Lotion w/    OTC Equivalents H2 Antagonists w/ OTC     Equivalents (Ulcer Meds) Acne Medications/ Products     with OTC Equivalents

Smoking Deterrents – OTC     (patches are included, all     other OTC smoking     cessation products are     excluded.) Vitamins – OTC Nexium Xopenex Magnacet

Drugs may be added to the Exclusion lists at any time.

Please be sure to verify coverage per plan programs and limitations. You may call PharmaCare Customer Service at 1-800-375-2596 or log in as a member at www.pharmacare.com/members.

* Certain contraceptive not covered under the prescription drug program such as IUDs and implantable contraceptives are covered under the health plan benefit. Please consult the QualChoice Summary Plan Description (SPD) for additional coverage details.

STEP PROGRAMS (ST):

Singulair Step Therapy

Singulair not covered for Allergic Rhinitis. Prior authorization required for treatment of Asthma. Member must currently be on a B2 Agonist (albuterol, etc) and an inhaled Corticosteroid (Pulmicort, Qvar), or Advair (which is a combination of B2 Agonist and Corticosteroid) to qualify for coverage.

Proton Pump Inhibitor (PPI) Program

All Proton Pump Inhibitors will require a 3rd tier co-pay except for OTC Prilosec and Omeprazole (ST). OTC Prilosec is covered at the generic co-pay when a valid prescription is presented to the pharmacy. (PPI's include Prilosec, Omeprazole, Prevacid, Aciphex, Protonix, and Zegerid. Nexium is not covered.) A 30 day trial of OTC Prilosec must be tried prior to Branded PPIs being covered.

COX2 Inhibitor Step Therapy

Member must try a 30-day supply of NSAIDS such as Ibuprofen or Naproxen before COX2 is covered, except in cases such as gastro-intestinal bleed risk or concurrent drug therapy problem. For these conditions a prior authorization is required for coverage of COX2 Inhibitors. (COX2 is Celebrex)

ARB Step Therapy

Member must try a 30-day supply of an ACE Inhibitor (Angiotensin II Converting Enzyme) before Angiotensin Receptor Blocker (ARB) is covered, or have serious ACE Inhibitor adverse affect. For these conditions a prior authorization is required. (ARB Examples: Diovan, Avalide, Benicar, Cozaar, Hyzaar, etc.)

Ranexa Step Therapy

Member must currently be taking a Beta Blocker (atenolol, Toprol XL, etc), Calcium Channel Blocker (verapamil, Norvasc), or a Nitrate (nitroglycerin, isosorbide). Claim will be denied at point of sale if a QT Prolongating medication like Antipsychotics (thioridiazine, Geodon) or Antiarrhythmics (quinidine, soltalol) has been filled within the last 45 days.

QUANTITY LIMITATIONS (QL):

Proton Pump Inhibitor (PPI) Limitations

Doses greater than one per day require a prior authorization. (PPIs include Prilosec, OTC Prilosec, Omeprazole, Prevacid, Aciphex, Protonix, and Zegerid. Nexium is not covered.)

COX2 Inhibitor Limitations

Doses greater than one per day require a prior authorization. (COX2s include Celebrex)

Migraine Therapies

All Migraine Therapy products are subject to Manufacturer Recommended Quantity Limits. (Migraine Therapy Examples: Imitrex, Amerge, Relpax, Zomig, Zomig ZMT, Axert, Frova, Maxalt, Maxalt MLT)

Smoking Cessation

Covered for 90-day length of therapy, one time only. Generic Nicotene Patches, only, will be covered for an additional 90-day therapy.

Tretinoin (Retin-A), Retinoids

Covered to age 25, then prior authorization required for non-cosmetic use.

Ambien and Sonata

Limited to 15 units per fill and only 15 units per rolling 30-day period. Copay applies for each 15-day supply.

Actiq/Fentora

Quantities greater than 6 units per 30 days require a prior authorization.

Blood Glucose Monitors

Once per calendar year.

Compounds

Covered up to $200 per fill. All compound medications are 3rd Tier.

The UofA Pharmacy Advisory Committee comprised of physicians, pharmacists, and benefit specialists makes all formulary, quantity, and day supply limitations decisions after careful consideration based upon published evidence-based medical data.