Nevada Dept of Health & Human Services


Benefits for Members Who Are NOT Eligible for Medicare Part D
Effective Date	January 1, 2006
Premium	None
Deductible	None

Retail Pharmacy Co-Pay:	Maximum 30 Day Supply
1. Generic	$10.00
2. Preferred Brand	$25.00
3. Non-Preferred Brand	100% of Discounted Rate, or if authorized as Medically Necessary, $25.00
Mail Order Co-Pay:	Maximum 90 Day Supply
1. Generic	$20.00
2. Preferred Brand	$50.00
3. Non-Preferred Brand	100% of Discounted Rate, or if authorized as Medically Necessary, $50.00
Generic Substitutions	Not Required
Refill Policy	Retail can be refilled when 75% of Rx is used Mail order can be refilled when 65% of Rx is used
Formulary	Managed Formulary**
Plan Maximum Per Member Per Year	$5,100.00

**A copy of the formulary is available upon request

Coverage for generic and preferred brand-name drugs is provided under the Senior Rx Prescription Drug Program for the co-pay options outlined above. If the prescription is for a non-preferred brand name drug, coverage is available if the drug is determined to be medically necessary. The co-pay for medically necessary non-preferred drugs is $25.00. If the non-preferred drug is not medically necessary, or is specifically excluded by the plan, it can be purchased at a discounted rate. This plan provides outpatient prescription drugs, when prescribed by a physician and filled at any Catalyst Rx participating pharmacy nationally.

Please note this is an OUTPATIENT Prescription Drug Program

Drugs or medicines taken by or administered during confinement in a hospital, nursing home, sanitarium, extended care facility, rest home or like institution, that has a dispensing facility on the premises or has contracted with a facility for dispensing drugs and medicines on the premises are not covered.
Any medication, legend or not, consumed or administered where it is dispensed is not covered.

Benefits for Members Who
ARE Eligible for Medicare Part D

Senior Rx members who are eligible for Medicare Part D must enroll in a Part D plan. In addition, members who are eligible for federal low-income subsidies (also known as �extra help�) must apply for and use this help. (Click Here for more information.) In some cases, the benefits and assistance available directly through Medicare will provide greater benefits than Senior Rx can offer. Otherwise, Senior Rx benefits include the following.

Senior Rx will subsidize an eligible member�s monthly Medicare Part D premium up to $20.56 in 2007. The subsidy is applicable to any Medicare Part D prescription drug plan the member selects. Any subsidy or �extra help� already provided to the member by Medicare is deducted from the amount that Senior Rx will pay. (Example: If Medicare pays $10, Senior Rx will pay $10.56.) Any premium amount in excess of $20.56 must be paid by the member. The premium subsidy is recalculated annually by Medicare, so the amount is subject to change in January of each year.

Senior Rx will cover 100% of the cost of a member�s prescription medications during the Medicare Part D coverage gap. (Click Here for more information ). The member must continue to follow his/her Medicare Part D prescription drug plan�s formulary (preferred drug list) and requirements for prior authorization and step therapy. Senior Rx coverage ends when Medicare Part D catastrophic coverage begins.