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1 SCAN Health Plan SCAN Health Plan Formulary List of Covered Drugs SCAN Health Plan 處方藥一覽表承保藥物清單 This formulary was updated on 11/01/2018. For more recent information or other questions, please contact SCAN Health Plan Member Services at (Medicare and Medi-Cal eligible members should call ) or, for TTY users, 711, 8 a.m. to 8 p.m., 7 days a week from October 1 to March 31. From April 1 to September 30, hours are 8 a.m. to 8 p.m. Monday through Friday (messages received on holidays and outside of our business hours will be returned within one business day), or visit 本處方藥一覽表更新於 2018 年 11 月 1 日 如需瞭解最新資訊或有其他疑問, 請聯絡 SCAN Health Plan 會員服務部, 電話 : ( 符合 Medicare 和 Medi-Cal 資格的會員可致電 ), 聽障人士請致電 711,10 月 1 日至 3 月 31 日期間的服務時間為每週七天, 上午 8 點至晚上 8 點 ;4 月 1 日至 9 月 30 日期間的服務時間為週一至週五, 上午 8 點至晚上 8 點 ( 節假日及營業時間之外收到的訊息將在一個工作日內回覆 ), 或瀏覽 19C-FOR900CH

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3 SCAN Health Plan 2019 Formulary (List of Covered Drugs) PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN 19468, 6 This formulary was updated on 11/01/2018. For more recent information or other questions, please contact SCAN Health Plan Member Services, at (Medicare and Medi-Cal eligible members should call ) or, for TTY users, 711, 8 a.m. to 8 p.m., 7 days a week from October 1 to March 31. From April 1 to September 30, hours are 8 a.m. to 8 p.m. Monday through Friday (messages received on holidays and outside of our business hours will be returned within one business day), or visit Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list (formulary) refers to we, us, or our, it means SCAN Health Plan. When it refers to plan or our plan, it means SCAN Classic (HMO), SCAN Classic II (HMO), Scripps Classic offered by SCAN Health Plan (HMO), Scripps Signature offered by SCAN Health Plan (HMO), SCAN Prime (HMO), SCAN Healthy at Home (HMO SNP), Heart First (HMO SNP), Scripps Heart First offered by SCAN Health Plan (HMO SNP), SCAN Balance (HMO SNP), SCAN Plus (HMO), Scripps Plus offered by SCAN Health Plan (HMO), SCAN Connections (HMO SNP), SCAN Connections at Home (HMO SNP). This document includes a list of the drugs (formulary) for our plan which is current as of November For an updated formulary, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit. Benefits, formulary, pharmacy network, and/or copayments/coinsurance may change on January 1, 2020, and from time to time during the year. This information is not a complete description of benefits. Call Member Services, at (TTY: 711) for more information. The Formulary and pharmacy network may change at any time. You will receive notice when necessary. You can get prescription drugs shipped to your home through our network mail order delivery program which is called Express Scripts Home Delivery. Typically, you should expect to receive your prescription drugs within 14 days from the time that the mail-order pharmacy receives the order. If you do not receive your prescription drug(s) within this time, please contact SCAN Health Plan Member Services at (Medicare and Medi-Cal eligible members should call ), 8 a.m. to 8 p.m., 7 days a week from October 1 to March 31. From April 1 to September 30, hours are 8 a.m. to 8 p.m. Monday through Friday (messages received on holidays and outside of our business hours will be returned within one business day). TTY:

4 SCAN Health Plan is an HMO plan with a Medicare contract. Enrollment in SCAN Health Plan depends on contract renewal. ATTENTION: If you speak another language, language assistance services, free of charge, are available to you. Call (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). 注意 : 如果您使用中文, 您可以免費獲得語言援助服務 請致電 ( 聽障專線 :711) Y0057_SCAN_10979_2018_C

5 Table of Contents.... What is the SCAN Health Plan Formulary?... 5 Can the Formulary (drug list) change?... 5 How do I use the Formulary?... 6 What are generic drugs?... 6 Are there any restrictions on my coverage?... 6 What if my drug is not on the Formulary?... 7 How do I request an exception to the SCAN Health Plan Formulary?... 7 What do I do before I can talk to my doctor about changing my drugs or requesting an exception?... 7 For more information... 8 SCAN Health Plan s Formulary Formulary Drugs Arranged by Therapeutic Class Formulary Drugs with Quantity Limits Index

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7 What is the SCAN Health Plan Formulary? A formulary is a list of covered drugs selected by SCAN Health Plan in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. SCAN Health Plan will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a SCAN Health Plan network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the Formulary (drug list) change? Generally, if you are taking a drug on our 2019 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2019 coverage year except when a new, less expensive generic drug becomes available, when new information about the safety or effectiveness of a drug is released, or the drug is removed from the market. (See bullets below for more information on changes that affect members currently taking the drug.) Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same costsharing for those members taking it for the remainder of the coverage year. Below are changes to the drug list that will also affect members currently taking a drug: New generic drugs. We may immediately remove a brand name drug on our Drug List if we are replacing it with a new generic drug that will appear on the same or lower cost sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different tier or add new restrictions. If you are currently taking that brand name drug, we may not tell you in advance before we make that change, but we will later provide you with information about the specific change(s) we have made. o If we make such a change, you or your prescriber can ask us to make an exception and continue to cover the brand name drug for you. The notice we provide you will also include information on the steps you may take to request an exception, and you can also find information in the section below entitled How do I request an exception to the SCAN Health Plan s Formulary? Drugs removed from the market. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug. Other changes. We may make other changes that affect members currently taking a drug. For instance, we may add a generic drug that is not new to market to replace a brand name drug currently on the formulary or add new restrictions to the brand name drug or move it to a different tier. Or we may make changes based on new clinical guidelines. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug to a higher tier, we must notify affected members of the change at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 30-day supply of the drug. The enclosed formulary is current as of November, To get updated information about the drugs covered by SCAN Health Plan, please contact us. Our contact information appears on the front and back cover pages. 5

8 How do I use the Formulary? There are two ways to find your drug within the formulary: Medical Condition The formulary begins on page 61. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents. If you know what your drug is used for, look for the category name in the list that begins on page number 61. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 91. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. What are generic drugs? SCAN Health Plan covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs. Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization: SCAN Health Plan requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from SCAN Health Plan before you fill your prescriptions. If you don t get approval, SCAN Health Plan may not cover the drug. Quantity Limits: For certain drugs, SCAN Health Plan limits the amount of the drug that SCAN Health Plan will cover. For example, SCAN Health Plan provides 30 tablets per prescription for Rozerem. This may be in addition to a standard one-month or three-month supply. Step Therapy: In some cases, SCAN Health Plan requires you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, SCAN Health Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, SCAN Health Plan will then cover Drug B. You can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 61. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. You can ask SCAN Health Plan to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the section, How do I request an exception to the SCAN Health Plan formulary? on page 7 for information about how to request an exception. 6

9 What if my drug is not on the Formulary? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered. If you learn that SCAN Health Plan does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by SCAN Health Plan. When you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that is covered by SCAN Health Plan. You can ask SCAN Health Plan to make an exception and cover your drug. See below for information about how to request an exception. How do I request an exception to the SCAN Health Plan Formulary? You can ask SCAN Health Plan to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make. You can ask us to cover a drug even if it is not on our formulary. If approved, this drug will be covered at a pre-determined level, and you would not be able to ask us to provide the drug at a lower level. You can ask us to cover a formulary drug at a lower level if this drug is not on the specialty tier. If approved this would lower the amount you must pay for your drug. You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, SCAN Health Plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover a greater amount. Generally, SCAN Health Plan will only approve your request for an exception if the alternative drugs included on the plan s formulary, the lower drug or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. You should contact us to ask us for an initial coverage decision for a formulary, tiering, or utilization restriction exception. When you request a formulary, tiering, or utilization restriction exception, you should submit a statement from your prescriber or physician supporting your request. Generally, we must make our decision within 72 hours of getting your prescriber s supporting statement. You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 72 hours for a decision. If your request to expedite is granted, we must give you a decision no later than 24 hours after we get a supporting statement from your doctor or other prescriber. What do I do before I can talk to my doctor about changing my drugs or requesting an exception? As a new or continuing member in our plan you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary but your ability to get it is limited. For example, you may need a prior authorization from us before you can fill your prescription. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. While you talk to your doctor to determine the right course of action for you, we may cover your drug in certain cases during the first 90 days you are a member of our plan. 7

10 For each of your drugs that is not on our formulary or if your ability to get your drugs is limited, we will cover a temporary 30-day supply if you are not in a long-term care facility or a 31-day supply if you are a resident of a long-term care facility. If your prescription is written for fewer days, we ll allow refills to provide up to a maximum 30-day supply of medication if you are not in a long-term care facility or a 31-day supply of medication if you are a resident of a long-term care facility. After your first 30-day supply if you are not in a long-term care facility or a 31-day supply if you are a resident of a long-term care facility, we will not pay for these drugs, even if you have been a member of the plan less than 90 days. If you are a resident of a long-term care facility and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug while you pursue a formulary exception. If you are a current member transitioning to a different level of care, you may be prescribed medications not on our formulary or your ability to get your drugs may be limited. In these instances, you need to talk with your doctor about the appropriate alternative therapies available on our formulary. If there are no appropriate alternative therapies on our formulary, you or your doctor can request an exception and ask the plan to cover the drug or remove restrictions from the drug. While you are talking with your doctor to determine the course of action, you are eligible to receive a 30-day transition supply of the drug if you are moving from a long-term care facility or a hospital stay to home or a 31-day transition supply of the drug if you are moving from home or a hospital stay to a long-term care facility. For more information For more detailed information about your SCAN Health Plan prescription drug coverage, please review your Evidence of Coverage and other plan materials. If you have questions about SCAN Health Plan, please contact us. Our contact information, along with the date we last updated the formulary, appears on the front and back cover pages. If you have general questions about Medicare prescription drug coverage, please call Medicare at MEDICARE ( ) 24 hours a day/7 days a week. TTY users should call Or, visit 8

11 The charts below list what you will pay as your share of the costs for covered prescription drugs when you are in the Initial Coverage Stage. Please refer to your Evidence of Coverage for more information. SCAN Classic (HMO): Los Angeles and Orange Counties Drug Tier Tier Name Retail & Mail-Order (30-day Standard Retail (30-day Retail (90-day Standard Retail (90-day Mail-Order (90-day 1 Generic $0 $5 $0 $10 $0 2 Generic $5 $12 $10 $24 $0 3 Brand $42 $47 $116 $131 $116 4 Non- Drug $95 $100 $275 $290 $275 5 Specialty Tier 33% 33% N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. is lower that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. We provide additional coverage of prescription drugs in tiers 1 and 2 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage. 9

12 SCAN Classic II (HMO): Los Angeles County Drug Tier Tier Name Retail & Mail-Order (30-day Standard Retail (30-day Retail (90-day Standard Retail (90-day Mail-Order (90-day 1 Generic $0 $5 $0 $10 $0 2 Generic $7 $14 $14 $28 $0 3 Brand $42 $47 $116 $131 $116 4 Non- Drug $95 $100 $275 $290 $275 5 Specialty Tier 33% 33% N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. is lower that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. We provide additional coverage of prescription drugs in tiers 1 and 2 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage. 10

13 SCAN Classic (HMO): Riverside and San Bernardino Counties Drug Tier Tier Name Retail & Mail-Order (30-day Standard Retail (30-day Retail (90-day Standard Retail (90-day Mail-Order (90-day 1 Generic $0 $7 $0 $14 $0 2 Generic $7 $14 $14 $28 $0 3 Brand $42 $47 $116 $131 $116 4 Non- Drug $95 $100 $275 $290 $275 5 Specialty Tier 33% 33% N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. is lower that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. We provide additional coverage of prescription drugs in tiers 1 and 2 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage. 11

14 SCAN Classic II (HMO): Riverside and San Bernardino Counties Drug Tier Tier Name Retail & Mail-Order (30-day Standard Retail (30-day Retail (90-day Standard Retail (90-day Mail-Order (90-day 1 Generic $2 $9 $4 $18 $0 2 Generic $7 $14 $14 $28 $0 3 Brand $42 $47 $116 $131 $116 4 Non- Drug $95 $100 $275 $290 $275 5 Specialty Tier 33% 33% N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. is lower that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. We provide additional coverage of prescription drugs in tier 1 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage. 12

15 Scripps Classic offered by SCAN Health Plan (HMO): San Diego County Drug Tier Tier Name Retail & Mail-Order (30-day Standard Retail (30-day Retail (90-day Standard Retail (90-day Mail-Order (90-day 1 Generic $0 $7 $0 $14 $0 2 Generic $5 $12 $10 $24 $0 3 Brand $42 $47 $116 $131 $116 4 Non- Drug $95 $100 $275 $290 $275 5 Specialty Tier 33% 33% N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. is lower that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. 13

16 Scripps Signature offered by SCAN Health Plan (HMO): San Diego County Drug Tier Tier Name Retail & Mail-Order (30-day Standard Retail (30-day Retail (90-day Standard Retail (90-day Mail-Order (90-day 1 Generic $0 $7 $0 $14 $0 2 Generic $3 $10 $6 $20 $0 3 Brand $42 $47 $116 $131 $116 4 Non- Drug $95 $100 $275 $290 $275 5 Specialty Tier 33% 33% N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. is lower that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. We provide additional coverage of prescription drugs in tiers 1 and 2 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage. 14

17 SCAN Classic (HMO): Ventura County Drug Tier Tier Name Retail & Mail-Order (30-day Standard Retail (30-day Retail (90-day Standard Retail (90-day Mail-Order (90-day 1 Generic $2 $9 $4 $18 $0 2 Generic $5 $14 $10 $28 $0 3 Brand $42 $47 $116 $131 $116 4 Non- Drug $95 $100 $275 $290 $275 5 Specialty Tier 33% 33% N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. is lower that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. 15

18 SCAN Classic (HMO): San Francisco and Santa Clara Counties Drug Tier Tier Name Retail & Mail-Order (30-day Standard Retail (30-day Retail (90-day Standard Retail (90-day Mail-Order (90-day 1 Generic $3 $10 $6 $20 $0 2 Generic $5 $12 $10 $24 $0 3 Brand $42 $47 $116 $131 $116 4 Non- Drug $95 $100 $275 $290 $275 5 Specialty Tier 33% 33% N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. is lower that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. 16

19 SCAN Classic (HMO): Napa and Sonoma Counties Drug Tier Tier Name Retail & Mail-Order (30-day Standard Retail (30-day Retail (90-day Standard Retail (90-day Mail-Order (90-day 1 Generic $0 $7 $0 $14 $0 2 Generic $10 $17 $20 $34 $0 3 Brand $42 $47 $116 $131 $116 4 Non- Drug $95 $100 $275 $290 $275 5 Specialty Tier 33% 33% N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. is lower that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. 17

20 SCAN Prime (HMO): Los Angeles and Orange Counties Drug Tier Tier Name Retail & Mail-Order (30-day Standard Retail (30-day Retail (90-day Standard Retail (90-day Mail-Order (90-day 1 Generic $0 $5 $0 $10 $0 2 Generic $5 $12 $10 $24 $0 3 Brand $42 $47 $116 $131 $116 4 Non- Drug $95 $100 $275 $290 $275 5 Specialty Tier 33% 33% N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. is lower that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. We provide additional coverage of prescription drugs in tiers 1 and 2 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage. 18

21 SCAN Prime (HMO): Riverside and San Bernardino Counties Drug Tier Tier Name Retail & Mail-Order (30-day Standard Retail (30-day Retail (90-day Standard Retail (90-day Mail-Order (90-day 1 Generic $0 $7 $0 $14 $0 2 Generic $7 $14 $14 $28 $0 3 Brand $42 $47 $116 $131 $116 4 Non- Drug $95 $100 $275 $290 $275 5 Specialty Tier 33% 33% N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. is lower that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. We provide additional coverage of prescription drugs in tiers 1 and 2 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage. 19

22 SCAN Healthy At Home (HMO SNP): Los Angeles, Orange, Riverside and San Bernardino Counties Drug Tier Tier Name Retail & Mail-Order (30-day Standard Retail (30-day Retail (90-day Standard Retail (90-day Mail-Order (90-day 1 Generic $0 $5 $0 $15 $0 2 Generic $5 $12 $15 $36 $0 3 Brand $42 $47 $126 $141 $126 4 Non- Drug $95 $100 $285 $300 $285 5 Specialty Tier 33% 33% N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. is lower that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. We provide additional coverage of prescription drugs in tier 1 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage. 20

23 Heart First (HMO SNP): Orange County Drug Tier Tier Name Retail & Mail-Order (30-day Standard Retail (30-day Retail (90-day Standard Retail (90-day Mail-Order (90-day 1 Generic $0 $5 $0 $10 $0 2 Generic $2 $9 $4 $18 $0 3 Brand $42 $47 $116 $131 $116 4 Non- Drug $95 $100 $275 $290 $275 5 Specialty Tier 33% 33% N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. is lower that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. We provide additional coverage of prescription drugs in tiers 1 and 2 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage. 21

24 Heart First (HMO SNP): Riverside and San Bernardino Counties Drug Tier Tier Name Retail & Mail-Order (30-day Standard Retail (30-day Retail (90-day Standard Retail (90-day Mail-Order (90-day 1 Generic $0 $7 $0 $14 $0 2 Generic $7 $14 $14 $28 $0 3 Brand $42 $47 $116 $131 $116 4 Non- Drug $95 $100 $275 $290 $275 5 Specialty Tier 33% 33% N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. is lower that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. We provide additional coverage of prescription drugs in tiers 1 and 2 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage. 22

25 Scripps Heart First offered by SCAN Health Plan (HMO SNP): San Diego County Drug Tier Tier Name Retail & Mail-Order (30-day Standard Retail (30-day Retail (90-day Standard Retail (90-day Mail-Order (90-day 1 Generic $0 $7 $0 $14 $0 2 Generic $5 $12 $10 $24 $0 3 Brand $42 $47 $116 $131 $116 4 Non- Drug $95 $100 $275 $290 $275 5 Specialty Tier 33% 33% N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. is lower that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. We provide additional coverage of prescription drugs in tier 1 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage. 23

26 Heart First (HMO SNP): Napa and Sonoma Counties Drug Tier Tier Name Retail & Mail-Order (30-day Standard Retail (30-day Retail (90-day Standard Retail (90-day Mail-Order (90-day 1 Generic $0 $7 $0 $14 $0 2 Generic $10 $17 $20 $34 $0 3 Brand $42 $47 $116 $131 $116 4 Non- Drug $95 $100 $275 $290 $275 5 Specialty Tier 33% 33% N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. is lower that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. We provide additional coverage of prescription drugs in tier 1 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage. 24

27 SCAN Balance (HMO SNP): Los Angeles and Orange Counties Drug Tier Tier Name Retail & Mail-Order (30-day Standard Retail (30-day Retail (90-day Standard Retail (90-day Mail-Order (90-day 1 Generic $0 $5 $0 $10 $0 2 Generic $2 $9 $4 $18 $0 3 Brand $30 $35 $80 $95 $80 4 Non- Drug $95 $100 $275 $290 $275 5 Specialty Tier 33% 33% N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. is lower that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. We provide additional coverage of prescription drugs in tiers 1 and 2 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage. 25

28 SCAN Balance (HMO SNP): Napa and Sonoma Counties Drug Tier Tier Name Retail & Mail-Order (30-day Standard Retail (30-day Retail (90-day Standard Retail (90-day Mail-Order (90-day 1 Generic $0 $7 $0 $14 $0 2 Generic $10 $17 $20 $34 $0 3 Brand $42 $47 $116 $131 $116 4 Non- Drug $95 $100 $275 $290 $275 5 Specialty Tier 33% 33% N/A N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. is lower that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. We provide additional coverage of prescription drugs in tier 1 in the Coverage Gap. Please refer to your Evidence of Coverage for more information about this coverage. 26

29 SCAN Plus (HMO): Los Angeles, Orange, Riverside, San Bernardino, San Francisco and Ventura Counties Drug Tier Tier Name Retail & Mail-Order (30-day Standard Retail (30-day Retail & Mail-Order (90-day Standard Retail (90-day 1 Generic $0 $19 $0 $57 2 Generic 25% 25% 25% 25% 3 Brand 25% 25% 25% 25% 4 Non- Drug 25% 25% 25% 25% 5 Specialty Tier 25% 25% N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. is lower that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. If you receive Extra Help, your share of the cost for covered prescription drugs may vary based on the level of Extra Help you receive. For more information about your drug costs, look at the LIS Rider. 27

30 Scripps Plus offered by SCAN Health Plan (HMO): San Diego County Drug Tier Tier Name Retail & Mail-Order (30-day Standard Retail costsharing (30-day Retail & Mail- Order costsharing (90-day Standard Retail (90-day 1 Generic $0 $19 $0 $57 2 Generic 25% 25% 25% 25% 3 Brand 25% 25% 25% 25% 4 Non- Drug 25% 25% 25% 25% 5 Specialty Tier 25% 25% N/A N/A Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. is lower that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. If you receive Extra Help, your share of the cost for covered prescription drugs may vary based on the level of Extra Help you receive. For more information about your drug costs, look at the LIS Rider. 28

31 The chart below is for Medicare and Medi-Cal eligible members only. It lists what you will pay as your share of the cost for covered prescription drugs when you are in the Initial Coverage Stage. For information about your costs in the Coverage Gap Stage or the Catastrophic Coverage Stage, please refer to your Evidence of Coverage. Co-pays may vary based on the level of Extra Help you receive. Please contact Member Services for further details. Our contact information appears on the front and back cover pages. SCAN Connections (HMO SNP) Medicare and Medi-Cal eligible members only: Los Angeles, Riverside and San Bernardino Counties SCAN Connections at Home (HMO SNP) Medicare and Medi-Cal eligible members only: Los Angeles, Riverside, and San Bernardino Counties Drug Tier Tier Name Retail & Mail-Order Standard Retail 1 Generic (One three month $0 $0 or $1.25 or $ Generic (One three month 3 4 Brand (One three month Non- Drug (One three month Generic drugs (including drugs treated like a generic): $0 or $1.25 or $3.40 All other drugs: $0 or $3.80 or $ Specialty Tier (One month supply only) Please refer to your Evidence of Coverage for information about the costs at Long-Term Care (LTC) pharmacies or out-of-network pharmacies. is lower that may be available to you for certain covered Part D drugs at certain network pharmacies. For more information, please visit our online searchable Pharmacy Directory at or call Member Services. Our contact information appears on the front and back cover pages. 29

32 SCAN Health Plan s Formulary The formulary that begins on page 61 provides coverage information about the drugs covered by SCAN Health Plan. If you have trouble finding your drug in the list, turn to the Index that begins on page 91. The first column of the chart lists the drug name. Brand name drugs are capitalized (e.g., JANUVIA) and generic drugs are listed in lower-case italics (e.g., metformin). The information in the Requirements/Limits column tells you if SCAN Health Plan has any special requirements for coverage of your drug. o o o o o o The symbol [PA] indicates that prior authorization applies. The symbol [B vs D] indicates that this drug may be covered under Medicare Part B or Part D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination. The symbol [ST] indicates that step therapy applies. The symbol [QL] indicates that quantities dispensed are limited. To see the quantity limit amount for the formulary drugs with quantity limits, turn to the page 88. The symbol [90D] indicates that the drug is available for a 90-day supply at Express Scripts mail-order and most retail pharmacies. The symbol [LD] indicates that limited distribution applies. This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Member Services at (Medicare and Medi-Cal eligible members should call ), 8 a.m. to 8 p.m., 7 days a week from October 1 to March 31. From April 1 to September 30, hours are 8 a.m. to 8 p.m. Monday through Friday (messages received on holidays and outside of our business hours will be returned within one business day). TTY:

33 SCAN Health Plan 2019 年處方藥一覽表 ( 承保藥物清單 ) 請閱讀 : 本文件包含關於本計劃承保藥物的資訊 19468, 6 本處方藥一覽表更新於 2018 年 11 月 1 日 如需瞭解最新資訊或有其他疑問, 請聯絡 SCAN Health Plan 會員服務部, 電話 : ( 符合 Medicare 和 Medi-Cal 資格的會員應致電 ), 聽障人士請致電 711,10 月 1 日至 3 月 31 日期間的服務時間為每週七天, 上午 8 點至晚上 8 點 ;4 月 1 日至 9 月 30 日期間的服務時間為週一至週五, 上午 8 點至晚上 8 點 ( 節假日及營業時間之外收到的訊息將在一個工作日內回覆 ), 或瀏覽 現有會員請注意 : 本處方藥一覽表自去年以來已經變更 請查看此文件, 確保其中仍包含您使用的藥物 本藥物清單 ( 處方藥一覽表 ) 中, 凡提述 我們 或 我們的 時, 均指 SCAN Health Plan 凡提述 計劃 或 我們的計劃 時, 均指 SCAN Classic (HMO) SCAN Classic II (HMO) Scripps Classic offered by SCAN Health Plan (HMO) Scripps Signature offered by SCAN Health Plan (HMO) SCAN Prime (HMO) SCAN Healthy at Home (HMO SNP) Heart First (HMO SNP) Scripps Heart First offered by SCAN Health Plan (HMO SNP) SCAN Balance (HMO SNP) SCAN Plus (HMO) Scripps Plus offered by SCAN Health Plan (HMO) SCAN Connections (HMO SNP) SCAN Connections at Home (HMO SNP) 本文件包含一份適用於我們計劃的藥物清單 ( 處方藥一覽表 ), 該清單最近更新於 2018 年 11 月 如需獲取最新的處方藥一覽表, 請聯絡我們 我們的聯絡資訊及處方藥一覽表的最近更新日期載於封面和封底 一般而言, 您必須使用網絡內藥房才能享受處方藥福利 自 2020 年 1 月 1 日起和在該年內, 福利 處方藥一覽表 藥房網絡和 / 或共付額 / 共同保險可能會不時有所調整 本資訊並非完整之福利敘述 請致電會員服務部, 電話 : ( 聽障專線 :711) 瞭解更多資訊 處方藥一覽表和藥房網絡可能會隨時變更 必要時您會收到通知 您可以要求透過我們的網絡內郵購快遞計劃 Express Scripts Home Delivery 將處方藥送達您的家中 一般而言, 您可在郵購藥房接獲訂單後 14 天內收到您的處方藥 如果您未在此時間內收到處方藥, 請聯絡 SCAN Health Plan 會員服務部, 電話 : ( 符合 Medicare 和 Medi-Cal 資格的會員可致電 ),10 月 1 日至 3 月 31 日期間的服務時間為上午 8 點至晚上 8 點, 每週 7 天 ;4 月 1 日至 9 月 30 日期間的服務時間為週一至週五, 上午 8 點至晚上 8 點 ( 節假日及營業時間之外收到的訊息將在一個工作日內回覆 ) 聽障專線 :711 31

34 SCAN Health Plan 是一項簽有 Medicare 合約的 HMO 計劃 能否在 SCAN Health Plan 註冊參保視合約續簽情況而定 ATTENTION: If you speak another language, language assistance services, free of charge, are available to you.call (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.llame al (TTY: 711). 注意 : 如果您使用中文, 您可以免費獲得語言援助服務 請致電 ( 聽障專線 :711) Y0057_SCAN_10979_2018_C_CH

35 目錄. 什麼是 SCAN Health Plan 處方藥一覽表? 處方藥一覽表 ( 藥物清單 ) 是否會變更? 如何使用處方藥一覽表? 什麼是普通藥? 對於我享受的承保範圍是否有任何限制? 若我的藥物不在處方藥一覽表上, 該怎麼辦? 如何申請 SCAN Health Plan 處方藥一覽表例外? 在向醫師提出變更藥物請求或提交例外處理申請之前, 我應該做什麼? 瞭解更多資訊 SCAN Health Plan 處方藥一覽表 處方藥一覽表上的藥物按治療類別排列 處方藥一覽表上有數量限制的藥物 索引

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37 什麼是 SCAN Health Plan 處方藥一覽表? 處方藥一覽表是 SCAN Health Plan 透過諮詢醫療提供者團隊所選出的受保藥物清單, 是高品質治療計劃中不可或缺的處方藥治療 只要具有醫療必要性, 且於 SCAN Health Plan 網絡內藥房配藥, 並遵守其他計劃規則,SCAN Health Plan 通常會承保列於我們處方藥一覽表中的藥物 要瞭解有關如何按您的處方配藥的更多資訊, 請查閱您的 承保範圍說明書 處方藥一覽表 ( 藥物清單 ) 是否會變更? 一般而言, 若您正在使用年初享受承保的 2019 年處方藥一覽表上的藥物, 我們不會在 2019 年承保年度中終止或減少此藥物的承保, 除非有更低價的新普通藥推出, 或者出現有關藥物安全性或有效性的最新資訊, 或者藥物退出市場 ( 請參閱下文, 詳細瞭解會影響目前正在使用藥物的會員的變更 ) 其他類型的處方藥一覽表變更 ( 例如從處方藥一覽表中刪除某種藥物 ) 不會對目前正在使用此藥物的會員產生影響 在承保年度剩餘時間內, 將以相同的共付額向使用此藥物的會員提供此藥物 以下藥物清單變更也會影響目前正在使用藥物的會員 : 新的普通藥 如果我們計劃以新的普通藥取代某一品牌藥, 而且這種普通藥將出現在相同或更低的分攤費用等級上且具有相同或更少的限制, 我們可能會立即將該品牌藥從藥物清單上刪除 另外, 在加入新普通藥時, 我們可能會決定將該品牌藥保留在藥物清單上, 但會立即將其移至其他分攤費用等級或增設限制 如果您正在使用該品牌藥, 在作出更改前我們可能不會提前告知您, 但是之後我們會向您提供有關我們所作的具體更改的資訊 o 如果我們作出更改, 您或您的處方醫師可以要求我們作出例外處理並繼續為您承保該品牌藥 我們向您發送的通知將詳細介紹如何申請例外處理, 您也可以在後面的 如何申請 SCAN Health Plan 處方藥一覽表例外? 章節中查看更多資訊 藥物退出市場 若美國食品及藥物管理局認為我們處方藥一覽表上的某種藥物不安全, 或藥物製造商從市場中撤除該藥物, 我們會立即從我們的處方藥一覽表上刪除該藥物, 並向使用該藥物的會員發出通知 其他變化 我們可能會作出影響目前正在使用藥物的會員的其他更改 例如, 我們可能會新增一種已上市一段時間的普通藥以取代處方藥一覽表上現有的品牌藥, 或對品牌藥添加新的限制條件, 或是將其移至其他費用分攤等級 我們也可能會根據新的臨床指南作出更改 如果我們從處方藥一覽表中移除了某些藥物, 對某個藥物新增了事先授權 數量限制和 / 或階段治療限制, 或提高某個藥物的費用分攤等級, 則我們必須在該更改生效前至少 30 天, 或在會員要求再次配藥時向受影響的會員發出通知 ( 該名會員將收到 30 天份的藥物 ) 35

38 隨附的處方藥一覽表更新於 2018 年 11 月 如需獲得有關 SCAN Health Plan 承保藥物的最新資訊, 請聯絡我們 我們的聯絡資訊載於封面和封底 如何使用處方藥一覽表? 有兩種方法在處方藥一覽表中查找您所需的藥物 : 病症 處方藥一覽表從第 61 頁開始 本處方藥一覽表中的藥物依照其所治療的病症類別分類 例如, 用來治療心臟病的藥物列在 心血管藥物 類別 如果您瞭解藥物的用途, 請在從第 61 頁開始的清單中查找類別名稱 然後, 在此類別名稱下查找所需的藥物 按字母順序排列的清單 如果您不確定要尋找什麼類別, 則可以利用從第 91 頁開始的索引來尋找您的藥物 該索引提供一份按字母順序排列的清單, 其中有本文件包含的所有藥物 該索引中列有品牌藥和普通藥 請在該索引中查找所需的藥物 藥物旁邊註有頁碼, 您可以在該頁查找承保範圍資訊 轉到該索引中所列的頁碼, 在清單的第一欄即可找到所需的藥物名稱 什麼是普通藥? SCAN Health Plan 同時承保品牌藥和普通藥 普通藥是一種由 FDA 核准, 具有與品牌藥相同活性成分的藥物 通常, 普通藥的費用比品牌藥低 對於我享受的承保範圍是否有任何限制? 某些承保藥物可能有其他要求或承保範圍限制 這些要求和限制可能包括 : 事先授權 : 對於某些藥物,SCAN Health Plan 要求您或您的醫師取得事先授權 這表示您將需要在配藥前取得 SCAN Health Plan 的核准 如果您未取得核准,SCAN Health Plan 可能不會承保該藥物 數量限制 : 對於某些藥物,SCAN Health Plan 限制了 SCAN Health Plan 承保的藥物數量 例如 : 對於 Rozerem,SCAN Health Plan 會為每份處方提供 30 片藥片 這可以另外附加在標準的一個月或三個月的供藥上 階梯療法 : 某些情況下,SCAN Health Plan 會要求您先嘗試使用某些藥物治療您的病症, 才會承保您使用另外一種藥物 例如, 假設藥物 A 和藥物 B 都能治療您的病症, 則在您嘗試使用藥物 A 前, SCAN Health Plan 可能不會承保藥物 B 藥物 A 對您無效時,SCAN Health Plan 才會承保藥物 B 您可以透過從第 61 頁開始的處方藥一覽表查詢您的藥物是否有額外的要求或限制 您也可以透過瀏覽我們的網站, 取得更多關於特定承保藥物限制的資訊 我們已在線上刊載文件, 解釋我們事先授權和階段療法的限制 您也可以要求我們寄一份給您 我們的聯絡資訊連同最後更新處方藥一覽表的日期載於封面和封底 36

39 您可以要求 SCAN Health Plan 對此類限制或使用上限作出例外處理, 或索取可能治療您的病症的其他相似藥物清單 請參見第 37 頁的 如何申請 SCAN Health Plan 處方藥一覽表例外? 章節, 瞭解有關例外申請方法的資訊 若我的藥物不在處方藥一覽表上, 該怎麼辦? 如果您的藥物不在此處方藥一覽表 ( 承保藥物清單 ) 上, 那麼您首先應該聯絡會員服務部, 詢問您的藥物是否在承保範圍內 如果您得知 SCAN Health Plan 並未承保您的藥物, 則您有兩種選擇 : 向會員服務部索要一份由 SCAN Health Plan 承保的相似藥物清單 收到該清單後, 請拿給您的醫師看, 並要求他 ( 她 ) 開處由 SCAN Health Plan 承保的相似藥物 您可以要求 SCAN Health Plan 作出例外處理, 並承保您的藥物 請查看以下關於如何申請例外處理的資訊 如何申請 SCAN Health Plan 處方藥一覽表例外? 您可以要求 SCAN Health Plan 對我們的承保規則作出例外處理 您可要求我們作出例外處理的類型有數種 您可以要求我們承保一種藥物, 即使它不在我們的處方藥一覽表上 如獲批准, 此藥物將按預定分攤費用等級獲得承保, 且您不得要求我們以更低的分攤費用等級提供此藥物 如果此藥物在處方藥一覽表上且不屬特殊藥物, 您可要求我們按更低的分攤費用等級承保此藥 如獲批准, 則可減少您必須為藥物支付的金額 您可以要求我們撤銷對您的藥物的承保限制 例如, 對於某些藥物,SCAN Health Plan 限制了藥物的承保數量 如果您的藥物有數量限制, 則可以要求我們撤銷限制並承保更多數量 通常, 只有在替代藥物處於計劃的處方藥一覽表上時, 或是較低分攤費用的藥物或額外的使用限制對於治療您的病症無法達到相同的效果時, 和 / 或可能造成副作用時,SCAN Health Plan 才會批准您的例外處理申請 您應當與我們聯絡, 要求我們做出針對處方藥一覽表 或使用限制例外處理的初始承保決定 在提出針對處方藥一覽表或使用限制例外處理申請時, 您應提交一份處方醫師或醫師的聲明來支持您的申請 通常, 我們在收到處方醫師的支持聲明後, 必須在 72 小時內做出決定 如果您或您的醫師認為等候 72 小時再作出決定會對您的健康造成嚴重傷害, 您可以申請加急 ( 快速 ) 例外處理 如果您的加急申請獲得批准, 我們在收到您的醫師或其他處方醫師的支持聲明後, 必須在 24 小時內為您做出決定 37

40 在向醫師提出變更藥物請求或提交例外處理申請之前, 我應該做什麼? 無論是本計劃的新會員還是老會員, 您可能正在使用我們處方藥一覽表上沒有的藥物 或者, 您正在使用一種在我們處方藥一覽表上的藥物, 但您在獲取該藥物時受到限制 例如, 您在開藥之前可能要獲得我們的事先授權 您應當先和您的醫師談談, 以決定您是否應該換用我們承保的適當藥物, 或提出處方藥一覽表例外處理申請以使我們承保您使用的藥物 在您與醫師討論以確定何種措施適合您時, 我們會在您成為計劃會員後的頭 90 天內針對某些情況為您的藥物提供承保 如果您的所有藥物都不在我們的處方藥一覽表上, 或您獲取藥物時受到限制, 則我們將承保 30 天 ( 您沒有住在長期護理機構時 ) 或 31 天 ( 您住在長期護理機構時 ) 的臨時供藥 如果您的處方天數較短, 我們將允許重新配藥, 提供最多 30 天 ( 您沒有住在長期護理機構時 ) 或 31 天 ( 您住在長期護理機構時 ) 的供藥 在您獲得 30 天 ( 您沒有住在長期護理機構時 ) 或 31 天 ( 您住在長期護理機構時 ) 的供藥後, 我們將不再為您支付這些藥物的費用, 即使您成為計劃會員還不足 90 天 如果您居住在長期護理機構且需要的藥物不在處方藥一覽表上, 或您獲取藥物時受到限制, 但您成為我們計劃的會員已超過 90 天, 則在您尋求處方藥一覽表例外處理時, 我們將會對該藥物承保 31 天份的緊急藥量 如果您是過渡到另一個護理等級的現任會員, 則給您開處的藥物可能會不在處方藥一覽表上, 或您獲得藥物時可能會受到限制 若出現上述情況, 您需要諮詢您的醫師來瞭解我們處方藥一覽表上是否有適當的替代療法 如果我們處方藥一覽表上沒有適當的替代療法, 您或您的醫師可提出例外請求, 要求本計劃承保您所用的藥物或解除對您所用藥物的限制 在您諮詢醫師以確定治療方案的同時, 您將有資格獲得 30 天 ( 您從長期護理機構或醫院搬回家時 ) 或 31 天 ( 您從家中或醫院搬到長期護理機構時 ) 的過渡期供藥 瞭解更多資訊 如需瞭解更多關於 SCAN Health Plan 處方藥承保的詳細資訊, 請查看您的 承保範圍說明書 及其他計劃資料 如果您對 SCAN Health Plan 有任何疑問, 請聯絡我們 我們的聯絡資訊連同最後更新處方藥一覽表的日期載於封面和封底 如果您對 Medicare 處方藥承保範圍有任何疑問, 請致電 Medicare, 電話 :1-800-MEDICARE ( )( 全天候熱線 ) 聽障和語障人士可致電 或瀏覽 38

41 下表列出了您在初始承保階段, 需要為承保範圍內的處方藥支付的分攤費用 請參閱您的 承保範圍說明書 瞭解更多資訊 SCAN Classic (HMO): 洛杉磯郡和橘郡 等級名稱 首選零售與郵購分攤費用 ( 網絡內 )( 30 天份的供藥 ) 標準零售分攤費用 ( 網絡內 )(30 天份的供藥 ) 首選零售分攤費用 ( 網絡內 )(90 天份的供藥 ) 標準零售分攤費用 ( 網絡內 )(90 天份的供藥 ) 郵購分攤費用 ( 網絡內 )( 90 天份的供藥 ) 1 首選普通藥 $0 $5 $0 $10 $0 2 普通藥 $5 $12 $10 $24 $0 3 首選品牌藥 $42 $47 $116 $131 $116 4 非首選藥物 $95 $100 $275 $290 $275 5 特殊級藥 33% 33% 不適用不適用不適用 如需瞭解長期護理 (LTC) 藥房或網絡外藥房費用的相關資訊, 請參閱您的 承保範圍說明書 首選分攤費用是指在特定網絡內藥房為某些 D 部分承保藥物支付的較低分攤費用 如需瞭解更多資訊, 請瀏覽我們線上的可搜尋 藥房目錄, 網址 : 或致電會員服務部 我們的聯絡資訊載於封面和封底 我們會在承保缺口階段額外承保第 1 級和第 2 級處方藥 關於此承保範圍的資訊, 請參閱 承保範圍說明書 39

42 SCAN Classic II (HMO): 洛杉磯郡 等級名稱 首選零售與郵購分攤費用 ( 網絡內 )( 30 天份的供藥 ) 標準零售分攤費用 ( 網絡內 )(30 天份的供藥 ) 首選零售分攤費用 ( 網絡內 )(90 天份的供藥 ) 標準零售分攤費用 ( 網絡內 )(90 天份的供藥 ) 郵購分攤費用 ( 網絡內 )( 90 天份的供藥 ) 1 首選普通藥 $0 $5 $0 $10 $0 2 普通藥 $7 $14 $14 $28 $0 3 首選品牌藥 $42 $47 $116 $131 $116 4 非首選藥物 $95 $100 $275 $290 $275 5 特殊級藥 33% 33% 不適用不適用不適用 如需瞭解長期護理 (LTC) 藥房或網絡外藥房費用的相關資訊, 請參閱您的 承保範圍說明書 首選分攤費用是指在特定網絡內藥房為某些 D 部分承保藥物支付的較低分攤費用 如需瞭解更多資訊, 請瀏覽我們線上的可搜尋 藥房目錄, 網址 : 或致電會員服務部 我們的聯絡資訊載於封面和封底 我們會在承保缺口階段額外承保第 1 級和第 2 級處方藥 關於此承保範圍的資訊, 請參閱 承保範圍說明書 40

43 SCAN Classic (HMO): 河濱郡和聖伯納迪諾郡 等級名稱 首選零售與郵購分攤費用 ( 網絡內 )( 30 天份的供藥 ) 標準零售分攤費用 ( 網絡內 )(30 天份的供藥 ) 首選零售分攤費用 ( 網絡內 )(90 天份的供藥 ) 標準零售分攤費用 ( 網絡內 )(90 天份的供藥 ) 郵購分攤費用 ( 網絡內 )( 90 天份的供藥 ) 1 首選普通藥 $0 $7 $0 $14 $0 2 普通藥 $7 $14 $14 $28 $0 3 首選品牌藥 $42 $47 $116 $131 $116 4 非首選藥物 $95 $100 $275 $290 $275 5 特殊級藥 33% 33% 不適用不適用不適用 如需瞭解長期護理 (LTC) 藥房或網絡外藥房費用的相關資訊, 請參閱您的 承保範圍說明書 首選分攤費用是指在特定網絡內藥房為某些 D 部分承保藥物支付的較低分攤費用 如需瞭解更多資訊, 請瀏覽我們線上的可搜尋 藥房目錄, 網址 : 或致電會員服務部 我們的聯絡資訊載於封面和封底 我們會在承保缺口階段額外承保第 1 級和第 2 級處方藥 關於此承保範圍的資訊, 請參閱 承保範圍說明書 41

44 SCAN Classic II (HMO): 河濱郡和聖伯納迪諾郡 等級名稱 首選零售與郵購分攤費用 ( 網絡內 )( 30 天份的供藥 ) 標準零售分攤費用 ( 網絡內 )(30 天份的供藥 ) 首選零售分攤費用 ( 網絡內 )(90 天份的供藥 ) 標準零售分攤費用 ( 網絡內 )(90 天份的供藥 ) 郵購分攤費用 ( 網絡內 )( 90 天份的供藥 ) 1 首選普通藥 $2 $9 $4 $18 $0 2 普通藥 $7 $14 $14 $28 $0 3 首選品牌藥 $42 $47 $116 $131 $116 4 非首選藥物 $95 $100 $275 $290 $275 5 特殊級藥 33% 33% 不適用不適用不適用 如需瞭解長期護理 (LTC) 藥房或網絡外藥房費用的相關資訊, 請參閱您的 承保範圍說明書 首選分攤費用是指在特定網絡內藥房為某些 D 部分承保藥物支付的較低分攤費用 如需瞭解更多資訊, 請瀏覽我們線上的可搜尋 藥房目錄, 網址 : 或致電會員服務部 我們的聯絡資訊載於封面和封底 我們會在承保缺口階段額外承保第 1 級處方藥 關於此承保範圍的資訊, 請參閱 承保範圍說明書 42

45 Scripps Classic offered by SCAN Health Plan (HMO): 聖地牙哥郡 等級名稱 首選零售與郵購分攤費用 ( 網絡內 )( 30 天份的供藥 ) 標準零售分攤費用 ( 網絡內 )(30 天份的供藥 ) 首選零售分攤費用 ( 網絡內 )(90 天份的供藥 ) 標準零售分攤費用 ( 網絡內 )(90 天份的供藥 ) 郵購分攤費用 ( 網絡內 )( 90 天份的供藥 ) 1 首選普通藥 $0 $7 $0 $14 $0 2 普通藥 $5 $12 $10 $24 $0 3 首選品牌藥 $42 $47 $116 $131 $116 4 非首選藥物 $95 $100 $275 $290 $275 5 特殊級藥 33% 33% 不適用不適用不適用 如需瞭解長期護理 (LTC) 藥房或網絡外藥房費用的相關資訊, 請參閱您的 承保範圍說明書 首選分攤費用是指在特定網絡內藥房為某些 D 部分承保藥物支付的較低分攤費用 如需瞭解更多資訊, 請瀏覽我們線上的可搜尋 藥房目錄, 網址 : 或致電會員服務部 我們的聯絡資訊載於封面和封底 43

46 Scripps Signature offered by SCAN Health Plan (HMO): 聖地牙哥郡 等級名稱 首選零售與郵購分攤費用 ( 網絡內 )( 30 天份的供藥 ) 標準零售分攤費用 ( 網絡內 )(30 天份的供藥 ) 首選零售分攤費用 ( 網絡內 )(90 天份的供藥 ) 標準零售分攤費用 ( 網絡內 )(90 天份的供藥 ) 郵購分攤費用 ( 網絡內 )( 90 天份的供藥 ) 1 首選普通藥 $0 $7 $0 $14 $0 2 普通藥 $3 $10 $6 $20 $0 3 首選品牌藥 $42 $47 $116 $131 $116 4 非首選藥物 $95 $100 $275 $290 $275 5 特殊級藥 33% 33% 不適用不適用不適用 如需瞭解長期護理 (LTC) 藥房或網絡外藥房費用的相關資訊, 請參閱您的 承保範圍說明書 首選分攤費用是指在特定網絡內藥房為某些 D 部分承保藥物支付的較低分攤費用 如需瞭解更多資訊, 請瀏覽我們線上的可搜尋 藥房目錄, 網址 : 或致電會員服務部 我們的聯絡資訊載於封面和封底 我們會在承保缺口階段額外承保第 1 級和第 2 級處方藥 關於此承保範圍的資訊, 請參閱 承保範圍說明書 44

47 SCAN Classic (HMO): 文圖拉郡 等級名稱 首選零售與郵購分攤費用 ( 網絡內 )( 30 天份的供藥 ) 標準零售分攤費用 ( 網絡內 )(30 天份的供藥 ) 首選零售分攤費用 ( 網絡內 )(90 天份的供藥 ) 標準零售分攤費用 ( 網絡內 )(90 天份的供藥 ) 郵購分攤費用 ( 網絡內 )( 90 天份的供藥 ) 1 首選普通藥 $2 $9 $4 $18 $0 2 普通藥 $5 $14 $10 $28 $0 3 首選品牌藥 $42 $47 $116 $131 $116 4 非首選藥物 $95 $100 $275 $290 $275 5 特殊級藥 33% 33% 不適用不適用不適用 如需瞭解長期護理 (LTC) 藥房或網絡外藥房費用的相關資訊, 請參閱您的 承保範圍說明書 首選分攤費用是指在特定網絡內藥房為某些 D 部分承保藥物支付的較低分攤費用 如需瞭解更多資訊, 請瀏覽我們線上的可搜尋 藥房目錄, 網址 : 或致電會員服務部 我們的聯絡資訊載於封面和封底 45