Your Prescription Benefit Program

Welcome to

Welcome to Magellan Rx Management Magellan Rx Management provides a wide range of prescription benefit programs

that emphasize quality and cost-effective healthcare solutions, driven to improve

overall health. We’re pleased to welcome you to your prescription benefit program.

To fill your prescription needs, we offer more than 64,000 pharmacies, repre-

senting major chain regional pharmacies and independent stores. To locate a

pharmacy, you can visit our website at magellanrx.com or contact one of our

Customer Service agents at the Rx Customer Service phone number located on

your identification card.

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

Management 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.

1

An Introduction to Your Prescription Benefit Program Your prescription benefit program is designed to help you and your eligible

dependents obtain prescription medications conveniently and at reasonable prices.

We are committed to:

• Providing a quality prescription benefit program that meets your needs and

the needs of your family.

• Promoting the use of safe, cost-effective and clinically appropriate

medications.

• Helping you save money and providing convenient access to your

prescription medications.

• Helping you achieve the best possible health outcomes.

This booklet is an important resource — along with the Magellan Rx Management

website (magellanrx.com) and our Customer Service Department, who can be

reached at the Rx Customer Service phone number located on your identification

card. We encourage you to review this booklet and visit our website to educate

yourself about your prescription benefit program. Understanding how your program

works will help you get the most out of your benefit.

Maximizing Your Benefits Generic MedicationsThere are now many generic products available to you on the market. 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 health care system — unless otherwise directed by

your physician. These medications have met the standards established by the Food

and Drug Administration (FDA). The FDA approves a generic equivalent if its safety,

purity, strength and effectiveness are proven to match that of the brand-name

product. Please refer to the label on your prescription container to determine if you

have received a generic equivalent.

2

In general, most plans require the use of generically equivalent products to obtain

savings for their members. 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) ProductsSome 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. These OTC products may represent a

reasonable therapeutic alternative to other medications in the same class of drugs

that still require a prescription. 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 ResourcesHealth Tools and Information are Just a Click AwayOur website, magellanrx.com, is a fast, easy, and secure way for you to compare

medication pricing, review prescription benefits in real time, manage your

prescription benefit and more-any time of the day or night. This new tool is part

of our continued effort to be your “one-stop” shop for all of your healthcare and

prescription drug needs.

Online tools available at magellanrx.com include: Prescription History, Find a

Pharmacy, Drug Information, Drug List, Member Health Education, Drug Pricing Tool,

and Medication Reminder.

3

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.

• Ask your physician or pharmacist what to do if you miss a dose.

• 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.

• 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.

• Keep medications away from heat, light and moisture. Never store

medications in the bathroom.

• Make taking your medications a part of your daily schedule.

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

properly discard your outdated medications.

*Food and Drug Administration, “How to Dispose of Unused Medicines,” October 2009.http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm101653.htm

4

Magellan Rx Management Formulary A Prescription Drug List, or formulary, is a list of brand-name and generic

medications that have undergone a careful review by a committee of practicing

physicians and pharmacists. This committee reviews new and existing medications

for safety and efficacy, and decides which medications provide quality treatment at

the best value.

The formulary is updated several times a year as new medications become

available and is subject to change. For the most up-to-date information, or for a full

formulary listing, visit magellanrx.com.

While the formulary is intended to provide a comprehensive coverage of your

prescription medication needs, there are some products that are not covered

or have limited availability. For medications that are not on the formulary or are

not covered by your prescription benefit program, talk to your physician about

alternative medications.

How Can I Find Out What Medications are On My Plan’s Formulary?The Magellan Rx Management Prescription Drug List is updated several times every

year as new medications become available. The list is subject to change. For the

most up-to-date information, visit magellanrx.com or call Customer Service at the

Rx Customer Service phone number located on your identification card.

For specific coverage and limitations information, as well as details about your

copay, please refer to your benefit plan documents.

5

Magellan Rx Management Quick Reference FormularyMost Commonly Prescribed MedicationsAll generic medications are listed on the Magellan Rx Management standard

formulary. Please use this quick reference list when you receive a prescription.

To receive maximum prescription drug benefits, ask your doctor to prescribe a

medication on this formulary. Remember, if a preferred drug from the formulary

is prescribed, your copay may be less than if a non-preferred drug is prescribed

for you. To see the complete Magellan Rx Management standard formulary, visit

magellanrx.com, or call Customer Service toll-free at the Rx Customer Service

phone number located on your identification card.

Drugs are listed alphabetically by brand name.

KeyLowest Copay = (generics)Middle Copay = Preferred BrandHighest Copay = Non-Preferred Brand*

ACCU-CHEK

acyclovir

ADVAIR DISKUS

ADVAIR HFA

allopurinol

ALPHAGAN P

alprazolam

AMITIZA

amitriptyline hcl

amlodipine besylate

amlodipine besylate- benazepril

ANDRODERM*

ANDROGEL 1.62% GEL*

ANORO ELLIPTA

APRISO

ARNUITY ELLIPTA

atenolol

atorvastatin calcium

azithromycin

AZOPT

benzonatate

BREO ELLIPTA

BRILINTA

bupropion hcl sr

bupropion xl

buspirone hcl

BYDUREON

BYETTA

BYSTOLIC

BYVALSON

CANASA

carvedilol

celecoxib

cephalexin

CIALIS

ciprofloxacin hcl

citalopram hbr

CLIMARA PRO

6

clindamycin phosphate

clobetasol propionate

clonazepam

clonidine hcl

clopidogrel

COLCRYS

COMBIGAN

COMBIVENT RESPIMAT

CREON

cyclobenzaprine hcl

dextroamphetamine- amphetamine er

diazepam

diclofenac sodium er

doxycycline hyclate

DUAVEE

duloxetine hcl

DYMISTA

ELIDEL*

EMBEDA*

escitalopram

esomeprazole magnesium

estradiol

fenofibrate

FLOVENT DISKUS

FLOVENT HFA

fluconazole

fluoxetine hcl

fluticasone propionate

furosemide

gabapentin

glimepiride

glipizide

HUMALOG

HUMALOG KWIKPEN

HUMALOG MIX

HUMULIN 70-30

HUMULIN N

HUMULIN R

hydrochlorothiazide

hydrocodone-acetamin- ophen

hydroxychloroquine sulfate

hydroxyzine hcl

ibuprofen

INCRUSE ELLIPTA

INVOKAMET

INVOKAMET XR

INVOKANA

JANUMET

JANUMET XR

JANUVIA

JARDIANCE

JENTADUETO

JENTADUETO XR

lamotrigine

LANTUS

LANTUS SOLOSTAR

LEVEMIR

levocetirizine dihydro- chloride

levothyroxine sodium

LINZESS*

lisinopril

lisinopril-hydrochlor- othiazide

lorazepam intensol

losartan potassium

losartan-hydrochlorothi- azide

lovastatin

LUMIGAN

meloxicam

metformin hcl

methocarbamol

methotrexate

methylphenidate hcl

methylprednisolone

metoprolol tartrate

metronidazole

minocycline hcl

MIRVASO

montelukast sodium

MOXEZA

mupirocin

MYRBETRIQ

naproxen

NATAZIA

NOVOLOG

NUVARING

7

omeprazole

ondansetron hcl

ONETOUCH

oxycodone hcl

oxycodone-acetamino- phen

pantoprazole sodium

paroxetine er

pioglitazone hcl

PRADAXA

pravastatin sodium

prednisolone

prednisone

PREMARIN

PREMPHASE

PREMPRO

PROAIR HFA

PROAIR RESPICLICK

PROCTOFOAM-HC

progesterone

propranolol hcl

PULMICORT FLEXHALER

PYLERA*

quetiapine fumarate

QVAR

RANEXA

ranitidine hcl

RAPAFLO

RENVELA

RESTASIS*

rosuvastatin calcium

SEREVENT DISKUS

sertraline hcl

simvastatin

SOLIQUA *

SOOLANTRA

SPIRIVA

spironolactone

sprintec

STIOLTO RESPIMAT

sulfamethoxazole- trimethoprim

sumatriptan succinate

SYMBICORT

SYNJARDY

SYNJARDY XR

SYNTHROID

tamsulosin hcl

testosterone cypionate

tizanidine hcl

topiramate / er

TOUJEO SOLOSTAR

TRADJENTA

tramadol hcl

TRAVATAN Z

trazodone hcl

triamcinolone acetonide

triamterene-hydrochloro- thiazide

TRULICITY

ULORIC*

valacyclovir

valsartan

valsartan-hydrochlor- othiazide

venlafaxine hcl

VENTOLIN HFA

VESICARE

VIAGRA

VICTOZA

VIGAMOX

VYVANSE

warfarin sodium

WELCHOL

XARELTO

zolpidem tartrate

ZOVIRAX*

8

Note: This is a partial list of medications that changes periodically. To ensure you have the most current version of the standard formulary, visit magellanrx.com, or call the Rx Customer Service phone number located on your identification card. 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.

Additional Requirements for Coverage or Limits on Certain Medications May Include:Prior AuthorizationYour prescription benefit program may have a prior authorization process for

certain medications. Prior authorization is a requirement that your physician obtain

approval from your health plan to prescribe a specific medication for you. Without

this prior approval, your health 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. We review requests for these

selected medications to help ensure appropriate and safe use of medications for

your medical condition(s). Your physician can call, fax, or submit prior authorization

requests electronically. For a list of select medications that require prior

authorization, please contact Customer Service at the Rx Customer Service phone

number located on your identification card.

9

Quantity Limits and Step Therapy 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.

Please consult the formulary on our website for more information.

Quantity LimitsFor 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 TherapyIn 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 looking in

the current formulary on

magellanrx.com, or by

calling Customer Service

at the Rx Customer Service

phone number located on

your identification card.

10

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 PhysiciansPrior Authorization Phone: Please refer to the Rx Customer Service phone number located on your identification card, Press option 4

Electronically magellanrx.com

Department HoursCustomer Service 24 hours a day, 7 days a week

In Case of EmergencyIn 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.

11

Medications ListAllergies to MedicationsUse the chart below to list all medications, both prescription and nonprescription,

to which you are allergic.

Medication Type of reaction, such as rash or breathing difficulties.

Prescription MedicationsUse the chart below to list all brand name and generic prescription medications you

currently take. Be sure to fill in all the information for each medication. The amount

of medication in each pill appears on the prescription label in milligrams (mg). The

dosage is the amount of medication in each pill multiplied by the number of pills

you take at one time.

MedicationPrescribing doctor

Reason for taking the medication

Dosage How often? (such as 3x/day)

12

MedicationPrescribing doctor

Reason for taking the medication

Dosage How often? (such as 3x/day)

13

About Magellan Rx Management We’re providing a smarter approach to pharmacy benefits – our integrated solution combines comprehensive prescription benefits management (PBM) services with specialty pharmacy expertise. We help members by providing safe and effective prescription drugs at the lowest total cost. Welcome to a unique vision of care. Welcome to Magellan Rx Management.

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.

14

MRXUNIVERSAL_1117