Pharmacy Benefits

Is there a pharmacy network? How many pharmacies are in the network? What major chains are not in the network? Is there a higher copayment for out-of-network pharmacies? What happens if an employee goes to a nonparticipating pharmacy, or if no network pharmacy is available?
Is there a drug formulary (a list of covered drugs)? What drugs are excluded?
How is the formulary determined?
Is there a different copay for generic equivalents of formulary brand-name drugs, or for nonformulary brand-name drugs?
Is there a mail order pharmacy program? What are the mail order copays?
Must maintenance drugs be purchased by mail?
How are brand-name drugs treated when no generic is available?
What if the patient is taking a nonformulary brand-name drug because he/she has tried a formulary drug or generic drug and is unable to use the less expensive drug?
Can the patient obtain the brand-name nonformulary drug at the formulary copay via an appeal or review?
If the patient is prescribed a brand-name drug but a generic is available, can the member still buy the brand-name drug, by paying the brand copay plus the difference in cost between the brand-name drug and the generic drug?
Are there drugs that are not covered, such as drugs for erectile dysfunction or weight loss?
Are there drugs that require prior authorization, such as growth hormones?
Are there quantity limits on certain drugs, such as migraine medication?
How are infertility drugs covered, if at all?
How are injectable drugs covered? Are members required to purchase injectable drugs at certain pharmacies or via a special program?
Does the plan cover allergy drugs such as Clarinex, Allegra, Zyrtec, Flonase, etc.? Are members required to try over-the-counter Claritin first?