Prescription Drugs
Supply Limits
Additional Coverage
Diabetic Injectable Insulin, Needles, and Syringes
Diabetic Supplies
Reimbursement Claims for Diabetic Supplies and Equipment

Prescription Drugs
The plan covers outpatient, self-administered medications and drugs that require a written prescription. "Prescription" refers to an order written by any licensed physician, or others licensed to prescribe (e.g., dentists) for a medicinal substance which, under the Federal Food, Drug, and Cosmetic Act (FDA), is required to bear on the packaging label the following legend: “Caution: Federal Law prohibits dispensing without a prescription,” or “Rx Only.”

The Prescription Drug Plan includes:

1. All legend drugs, unless specified otherwise.
2. Drug Efficacy Study Implementation Program (DESI) drugs as determined by the FDA (Food and Drug Administration) as lacking substantial evidence of effectiveness. The DESI drugs do not have studies to back up the medications' uses, but since they have been used and accepted for many years without significant safety problems, they continue to be used in today's marketplace. Examples of covered DESI drugs include Donnatal, Librax, and Tigan suppositories.
3. Controlled substance 5 (CV), nonprescription or over-the-counter (OTC) drugs, for example, Robitussin A-C syrup and Naldecon-CX. Federal law designates these medications as OTC. However, depending on certain state pharmacy laws, the medications may be considered legend prescription medications and are, therefore, all covered. These are the only OTC medications covered by the plan.
4. Compounded medications are covered if all of the following criteria are met:
   A. The product contains at least one covered active prescription ingredient and
   B. The prescription active ingredient(s) is FDA-approved for medical use in the United States via the same route of administration and
   C. The compounded product is not a copy of commercially available FDA-approved drug product and
   D. The safety and effectiveness of use for the prescribed indication is supported by FDA-approval or adequate medical and scientific evidence in the medical literature.
   
   Please note, compounded medications can not be filled at Walgreens mail Service Pharmacy.
   

FDA approval of a drug does not guarantee coverage by the plan. New drugs are subject to review by SXC and the University before being covered or excluded.

Current lists of drugs covered or excluded by the plan are available. Drug list are subject to change.

Supply Limits
The U-M prescription drug plan allows members to purchase up to 90-day supplies of medication from a retail pharmacy. Members on a tier co-pay plan may still order 90-day supplies through the Walgreens Mail Service for two co-pays, a 33% savings over retail.

Drug plan members have the following options for filling prescriptions at pharmacies in the SXC network:

• One-month supply (up to 34 days) for one (1) co-pay
• Two-month supply (35 to 60 days) for two (2) co-pays
• Up to 90-day supply for two (2) co-pays at Walgreens Mail Service
• Three-month supply (61 to 90 days) for three (3) co-pays

To have a 90-day supply dispensed, your physician must write your prescription for 90-day quantities. Please discuss this with your physician at your next regularly scheduled appointment.

Additional Coverage
The prescription drug plan also includes coverage for emergency allergic reaction kits; birth control medications, including oral and emergency contraceptives; contraceptive devices and implant contraceptives. Certain medications and drugs are limited, excluded or require prior authorization from the plan. For details, see Exclusions, Limitations, Prior Authorizations (PA), Dose Optimization, Step Therapy, and Self-Administered Injectable Medications.

Diabetic Injectable Insulin, Needles and Syringes
Diabetic injectable insulin, needles and syringes are available to all participants in the University of Michigan prescription drug plan at a zero ($0) co-pay when the U-M SXC prescription drug ID card is used at a network retail pharmacy, or from the Walgreens Mail Service pharmacy.

Diabetic Supplies
Coverage of diabetic supplies (injection devices, alcohol swabs, testing strips, lancets, and blood glucose testing monitors) is determined by your medical insurance plan participation as described below.

Participants in the University of Michigan Prescription Drug Plan can receive diabetic supplies at a zero ($0) co-pay only when the medical insurance ID card is used at an authorized provider. Contact your medical insurance plan administrator (UM Premier Care, Priority Health, Health Alliance Plan, or Blue Cross Blue Shield of Michigan) for further instructions on how to obtain diabetic supplies through the medical plan.

Reimbursement Claims for Diabetic Supplies and Equipment
For diabetic supplies purchased out-of-pocket and then submitted for reimbursement, the refund may be reduced to the price contracted with authorized DME providers. Submit claim forms to your medical plan.