Go to magellanrx.com for a fast, easy and secure way to manage your pharmacy benefits.

At magellanrx.com you can: view prescription history, find a pharmacy, research drug information, review your formulary/drug list, receive health education, use our pricing tool, and set up medication reminders.

Visit magellanrx.com today!

Welcome to Magellan Rx Management

Magellan Rx Management Contact Information

Departments/services for members

Website magellanrx.com

Customer Service Please refer to the Rx Customer Service phone number located on your identification card

Customer Service National TRS, Dial 711 (For the hearing impaired) (Provide 800# above)

Departments/services for physicians

Prior Authorization Please refer to the Rx Customer Service

phone number located on your identification card

Electronically magellanrx.com

Department hours

Customer Service 24 hours a day, seven days a week

In case of emergency

In the event of an emergency or natural disaster, contact Customer Service for assistance. We will help you obtain an immediate refill at a local pharmacy if needed.

Reporting Medication Errors

If you believe you are experiencing or have experienced a medication error event, please contact your doctor and then email the details to MRxQualityDepartment@magellanhealth.com.

How to find information about your planFor the most up-to-date information about your prescription benefit program, visit us online at magellanrx.com or call Customer Service at the Rx Customer Service phone number located on your identification card.

Welcome toMagellan Rx ManagementMagellan Rx Management provides a wide range of prescription benefit programs that emphasize quality and cost-effective healthcare solutions, driven to help you and your family live healthy, vibrant lives. To fill your prescription needs, we offer a robust pharmacy network with major chains, regional pharmacies and independent stores. To locate a network pharmacy, you can visit our website at magellanrx.com.

Please present your identification card along with your prescription to any participating pharmacy to receive your medication. If you have any questions regarding your prescription benefit program, please call Magellan Rx Customer Service at the Rx Customer Service phone number located on your identification card. We are open 24 hours a day, 7 days a week.

We encourage you to review these materials and visit our website at magellanrx.com to educate yourself about your pharmacy benefit program. Understanding how your program works will help you get the most out of your benefit.

Maximizing Your Benefits

Generic Medications

Generic medications provide quality, cost-effective alternatives to brand medications. One or more of your prescriptions may be filled with a pharmaceutically equivalent generic product. We use generic equivalents, whenever possible, in order to reduce costs to you, your Plan and the healthcare system — unless otherwise directed by your physician. You may request a brand-name medication by notifying us on your prescription order. The brand-name product may be subject to a higher cost or copay as determined by your Plan.

Over-the-Counter (OTC) Products

Some brand-name drugs previously available by prescription-only are now available over-the-counter (OTC). For example, drugs such as Claritin®, Prevacid® 24HR, Prilosec OTC®, and Zyrtec® no longer require a prescription and are the same strength as their prescription versions. In consultation with your physician, consider an OTC product as it may be a lower cost option to treat your condition. If your Plan provides OTC coverage, you may be eligible for additional benefits.

Online Tools at magellanrx.com

Secure online connection protecting your confidentiality and providing:

• Easy-to-use tools that allow you to view, refill, renew and transfer prescriptions

• Drug formulary and lookup tools

• Trusted drug and health condition information and education

• Real-time benefit information

• Access to view and download pharmacy claims

• A participating pharmacy locator tool

• Downloadable claim and mail service forms

• Drug recall communications

Taking Your Medications As Directed

Taking medications exactly as prescribed is one of the most important things you can do to enhance your health and prevent medical complications. Missing doses, stopping medication early or swapping medications with other people can lead to serious problems. Here are a few tips to help you get the greatest benefit from your medications:

• Read labels carefully before taking each medication. Take each medication as prescribed by your physician. For example, take the correct number of doses each day, at the correct time of day.

• Talk to your physician or pharmacist before you stop taking a medication. Do not stop taking a medication just because you feel better. Ask your physician or pharmacist what to do if you miss a dose.

• Talk to your physician or pharmacist before crushing or splitting tablets; some medications need to be swallowed whole.

• Keep a record of all your current medications, including their names and regimens (dose, time and other instructions). Write down any problems you have with your medications, and discuss them with your physician or pharmacist.

• Properly discard all outdated medications. Call Customer Service, visit magellanrx.com, or review FDA guidelines1 for information on how to properly discard your outdated medications.

Additional Requirements and Coverage Limits

Your Plan may have additional requirements for coverage or limits for select prescription medications. These requirements and limits ensure that members use these medications in the most effective way and also help the Plan control medication costs. A team of practicing physicians and pharmacists developed these requirements and limits to help your Plan provide quality coverage to members.

• Prior Authorization: Your prescription benefit program may have a prior authorization process for certain medications. Prior authorization is a requirement that your physician obtain approval from your Plan to prescribe a specific medication for you. Without this prior approval, your Plan may not provide coverage for your medication. If your physician prescribes a medication requiring a prior authorization, you will need to go through a prior authorization process.

• Quantity Limits: For certain medications, your Plan may limit the amount of the medication that will be covered per prescription or for a defined period of time. For example, your Plan may provide up to 30 units per 30-day period for a formulary medication.

• Step Therapy: In some cases, your Plan requires you to first try one medication to treat your medical condition before it will cover another medication for that condition. For example, if Drug A and Drug B both treat your medical condition, your Plan may require your physician to prescribe Drug A first. If Drug A does not work for you, then your Plan will cover Drug B.

You can find out if the medication you take is subject to these or other additional requirements or limits by reviewing the current formulary on magellanrx.com or by calling Customer Service at the Rx Customer Service phone number located on your identification card.

1. Food and Drug Administration, “Where and How to Dispose of Unused Medicines,” September, 2019. http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm101653.htm

If you take maintenance medications for long-term conditions like arthritis, asthma, diabetes, high blood pressure or high cholesterol, you could save with home delivery through Magellan Rx Pharmacy.

Home delivery by Magellan Rx PharmacySave time and money with a 90-day supply of your medications by mail

How to get startedGetting started with home delivery is easy! First, ask your doctor to write two prescriptions:

1. 30-day supply to fill at your local pharmacy

2. 90-day supply plus refills to fill by mail

Next, you may either:

Ask your doctor to e-prescribe to Magellan Rx Pharmacy, LLC (Mail-ORL) or fax your prescription to 888-282-1349.

₀ Faxed prescriptions may only be sent by a doctor’s office and must include patient information and diagnosis.

₀ For prompt delivery, please provide your payment information by mailing in your completed order form or by calling 800-424-8274.

Mail us your 90-day prescription and completed order form with payment to Magellan Rx Pharmacy, P.O. Box 620968, Orlando, FL 32862.

₀ Home delivery order forms are available at www.magellanrx.com/member/forms

Depending on your plan design, you may be able to get a 90-day supply of your medication for less money than three separate fills. And standard shipping is free!

Easily refill your medication one time every three months either online or by phone. That means no more drive time or waiting at the pharmacy!

Your medication is mailed to you, quickly and securely. Registered pharmacists check all orders and are available to help 24 hours a day, 7 days a week.

Save money Save time Peace of mind

magellanrx.com2019 Magellan Rx Management, LLC. All rights reserved. MRX1098_0919

Member and physician informa�on. Please use black or blue ink. One form per member.Member ID Number

Last Name First Name MI

Delivery Address Apt. #

City State ZIP

(_____)______________________M H W

(_____)______________________M H W

(_____)______________________M H W

Best �me to be reached: AM PM

Date of Birth

Gender M F

Email

Physician Name Physician Phone Number ( )

Health historyMedica�on Allergies:

None KnownHealth Condi�ons:

None Known

List all prescrip�on, over-the-counter and herbal medica�ons taken regularly:

Amoxil/Ampicillin Aspirin Cephalosporins

Codeine

ErythromycinNSAIDsPenicillinQuinolones

SulfaTetracyclinesOthers:

Arthri�sAsthmaCancerDiabetes

GlaucomaHeart Condi�onHigh Blood PressureHigh Cholesterol

OsteoporosisThyroid DiseaseOthers:

Home Delivery Order Form

1

2

Pharmacy processing

Keep on file: If you are including any prescrip�ons that you want to keep on file for shipment at a later date, please list them here:

Notes to Pharmacy:

Payment and shipping informa�on — do not send cash.

Cardholder Signature: Date:

Credit card number (VISA®, MasterCard®, Discover®, or American Express®are accepted.) and expira�on date (month/year)

/

5

Refills. To order home delivery refills, enter your prescrip�on number(s):

4

3

/ /

Phone Number (list in order of preference)(circle one)

(use addi�onal sheet if necessary)

1: _______________________ 2: ________________________ 3: _________________________ 4: __________________________5: _______________________ 6: ________________________ 7: _________________________ 8: __________________________

magellanrx.com2019 Magellan Rx Management, LLC. All rights reserved. MRX1001_0819

Generic substitution: FDA-approved generic equivalents will be dispensed for brand-name drugs whenever possible, unless you or your physician indicate otherwise. Brand-name medica�ons may be subject to a higher cost. Generic equivalents are usually less expensive than brand name drugs. If we dispense a brand name drug, you may be responsible for a higher copayment and/or the difference between the brand and generic price of each drug. If allowed by your prescriber, we will dispense a generic equivalent unless you check this box. I do not accept a generic equivalent.

For new prescrip�on orders and maintenance refills, this credit card will be billed for copay/coinsurance, and other such expenses related to prescrip�on orders. By supplying my credit card number, I authorize Magellan Rx Management to maintain my credit card on file as payment method for any future charges. To modify payment selec�on, Customer Service can be contacted at any �me.

Standard delivery is included at no charge. Most prescrip�on orders arrive within 7 days from the date your order is received. We will contact you if there is an extended delay in delivering your medica�ons. Please call 800.424.8274 if you have any ques�ons. Once shipped, medica�ons may not be returned for a refund or adjustment. Visit www.magellanrx.com to download addi�onal order forms.

6Mail this completed order form with your new prescrip�on(s) to Magellan Rx Pharmacy, P.O. Box 620968, Orlando, FL 32862. DO NOT STAPLE OR TAPE PRESCRIPTIONS TO THE ORDER FORM.

Complete your order form

I authorize Magellan Rx to charge the following amount to my credit/debit card without prior no�fica�on: ____up to $150 ____up to $250 ____up to $________ (other amount greater than $250)

Ship overnight. (addi�onal charges will apply). Please call to verify pricing. No P.O. BOX overnight shipping.

Charge to my NEW credit card.

Check enclosed. All checks must be signed and made payable to: Magellan Rx Pharmacy.

Charge to my credit card on file.

Magellan Rx Pharmacy

magellanrx.com2020 Magellan Rx Management, LLC. All rights reserved. Standard_MRX0137_1019

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sildenafil*SIMBRINZAsimvastatinSOLIQUA*SOOLANTRASPIRIVA/RESPIMATspironolactoneSTIOLTOsumatriptan succinateSYMBICORTSYMPROIC*SYNJARDYSYNJARDY XRtamsulosin hcltestosterone cypionatetizanidine hcltopiramateTOUJEO MAX SOLOSTARTOUJEO SOLOSTARTRADJENTAtramadol hclTRAVATAN Ztrazodone hclTRELEGYTRESIBA FLEXtretinointriamcinolone acetonidetriamterene-hydrochlorothiazideTRULICITYvalacyclovirvenlafaxine hcl erVENTOLIN HFAVICTOZAVYVANSEwarfarin sodiumXARELTOXARELTO STARTER PACKXELPROSXIIDRA*ZENPEPzolpidem tartrateZUBSOLV*

Generic Medications Listed in all lower-case letters

Preferred Brand Name Medications Listed in all upper-case letters

Medications requiring ST or PA Listed with an asteriskv (*)

Note: This is a partial list of medications that changes periodically. To ensure you have the most current version of the formulary, visit magellanrx.com. Inclusion of a medication on this formulary is not a guarantee of coverage. Please refer to your plan of benefits for coverage limitations and exclusions. Not all benefits plans in all states are subject to quantity limits. For details regarding quantity limits for your particular benefits plan, contact Customer Service at the telephone number listed on your identification card.

Updated 10/2019, Effective 1/2020 Key

2020Standard Quick Reference FormularyMost Commonly Prescribed MedicationsThe Standard Quick Reference Formulary is intended to provide a list of commonly prescribed drugs that are covered. This is not an all-inclusive list, the formulary covers many more drugs. On the Quick Reference, generic drugs are listed in lower case italics, and brand drugs are listed in CAPS. Remember, if a generic drug from the formulary is prescribed, the copay may be less than if a brand drug is prescribed. If the drug has step therapy or prior authorization on the formulary at the time of publishing, it is indicated below with a star (*). There are other safety edits that are not listed because of the abbreviated nature of this document. Individual plan designs may also change coverage of products listed. To see the complete listing of covered products please visit magellanrx.com.

Drugs are listed alphabetically.

magellanrx.com2019 Magellan Rx Management, LLC. All rights reserved. MRX1013_0519

At Magellan Rx Management we are dedicated to providing quality service and personalized care. We make it easy for you to quickly get your specialty medications while providing additional support to help you stay on track.

Services and programs to support your needsWhen you enroll, a representative will contact you to gather important information to schedule your first delivery from Magellan Rx Pharmacy. We will stay in touch over the course of your therapy and will call with monthly refill reminders and address any questions you may have about your treatment. In addition, you also have access to many helpful services:

• Insurance specialists to help you get the most out of your benefits

• Clinical programs to help manage your condition

• Educational materials about your condition or medication, including at-home guides

• Free delivery to your home or another address within two days of ordering

• Important supplies at no additional cost, such as syringes and needles

• Highly-trained pharmacists and nurses available toll-free to answer any questions

• Online member portal where you can request refills and learn more

• Copay assistance programs which can reduce or eliminate your out of pocket costs

Ordering your medication is fast and easyStep 1: Enroll Online - visit magellanrx.com/member/forms and click on

Specialty Patient Enrollment Form

Step 2: Have your doctor e-prescribe Magellan Rx Pharmacy - Specialty or fax your prescription to us at 866-364-2673. Make sure the form includes your contact information. If prior authorization is required, your doctor may need to take additional steps to submit your prescription.

Step 3: We will contact you to get important information and schedule your first delivery.

Step 4: Your prescription will arrive when and where requested.

We are here to helpIf you have any questions about our services or your specialty medications, please contact us at 866-554-2673. Our standard hours are Monday through Friday from 8:00am to 10:00pm ET. Representatives are also available 24/7 for urgent requests.

Welcome to Your Specialty Pharmacy