1. A. Prescription Drug Benefits

   Network Pharmacy	Member pays
   Tier 1- Generic	50% up to $30
   Tier 2- Preferred	50% up to $55
   Tier 3- Non-preferred	65% up to $80
   Tier 4- Specialty	50% up to $80
   90 day supplies for maintenance drugs from mail order OR at participating 90-day retail network pharmacies	Two and a half times the cost of your applicable copayment
   Co-Payment after the Out Of Pocket Amount of $1,500 Is Met
   Tier 1- Generic	$0
   Tier 2- Preferred	$20
   Tier 3- Non-preferred	$40
   Tier 4- Specialty	$40
   Prescription drug benefits-31 day refill
   Plan pays balance of eligible expenses
   Diabetic supplies are not subject to a copayment if enrolled in the In-Health/Disease Management Program.
   Member who chooses a brand-name drug for which an approved generic version is available, pays the cost difference between the brand-name drug & the generic drug, plus the co-pay for the brand-name drug; the cost difference does not apply to the $1,500 out of pocket amount.
   Medications available over-the-counter in the same prescribed strength are not covered under the pharmacy plan.
   Smoking Cessation Medications: Benefits are available for Prescription and over-the-counter (OTC) smoking cessation medications when prescribed by a physician. (Prescription is required for over-the-counter medications). Smoking cessation medications are covered at 100%.
   This plan allows benefits for drugs and medicines approved by the Food and Drug Administration or its successor that require a prescription. Utilization management criteria may apply to specific drugs or drug categories to be determined by PBM.

2. B. OGB shall have discretion to adopt a pharmacy benefits formulary to help enrollees select the most appropriate, lowest-cost options. The formulary will be reviewed on a quarterly basis to reassess drug tiers based on the current prescription drug market. The formulary may be changed from time to time subject to any applicable advance notice requirements. The amount enrollees pay toward prescription medications will depend on whether they purchase a generic, preferred brand, non-preferred brand, or specialty drug.

Authority Note

AUTHORITY NOTE: Promulgated in accordance with R.S. 42:801(C) and 802(B)(1).

Historical Note

HISTORICAL NOTE: Promulgated by the Office of the Governor, Division of Administration, Office of Group Benefits, LR 41:360 (February 2015), effective March 1, 2015, amended LR 43:2158 (November 2017), effective January 1, 2018, LR 50:782 (June 2024).