Transcription
Cleveland ClinicCleveland ClinicEHP Total Care/SummaCare EPOPrescription Drug Benefitand Formulary Handbook
Your Guide toQuality Healthcare Servicesand Healthier LivingWelcome to the Cleveland Clinic Employee Health Plan (EHP) Total Care/SummaCare EPO Prescription Drug Benefit Program. As a Cleveland Clinic orRegional hospital employee, you have access to a comprehensive prescriptiondrug benefit. To help you understand the benefits available to you under thisprogram, EHP Total Care has developed this Prescription Drug Benefit and FormularyHandbook (hereafter referred to as the Handbook).This Handbook defines your prescription drug coverage. We encourage you to takethe time to read this information carefully. You may wish to consider taking thisHandbook with you when you visit your healthcare provider(s) to aid in the selectionof effective, safe, and value-based prescription drug therapy. This information is alsoavailable on the Cleveland Clinic website at www.clevelandclinic.org/healthplan.You will find helpful information about: Where you can get your prescriptions filled; The EHP Total Care/SummaCare EPO Prescription Drug Formulary; The Mandatory Maintenance Program; Prior Authorization and Formulary Exception Program; Quantity Limit and Step Therapy Programs; and The Specialty Drug ProgramAdherence to your prescribed drug therapy plan is critical to improving yourquality of life and decreasing your out-of-pocket expenses in the long run. EHPTotal Care looks forward to assisting you with your prescription drug benefit needs.iii
Table of ContentsCLEVELAND CLINIC EHP TOTAL CARE PRESCRIPTION DRUG BENEFITPrescription Drug Benefit Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Prescription Drug Benefit Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Understanding The Formulary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .EHP Total Care/SummaCare EPO Prescription Drug Benefit Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Filling Your Prescriptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Cleveland Clinic Pharmacies and Home Delivery Pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Cleveland Clinic Pharmacies — Locations and Hours of Operation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Cleveland Clinic Home Delivery Pharmacy Ordering Instructions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Processing Form Sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Advantages of Utilizing the Cleveland Clinic Pharmacies and Home Delivery Pharmacy . . . . . . . . . . . . . . . . . . . . . .CVS Caremark Retail Pharmacy Network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .CVS Caremark Mail Service Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .New Prescriptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Mail Service Refills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Prescription Drug Benefit Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Prescription Drug Benefit — Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Deductible and Out-Of-Pocket Maximum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Generic Medication Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Prior Authorization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Pharmaceuticals Requiring Prior Authorization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Formulary Failure Review Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Instructions for a Physician on How to Complete the Prior Authorization/Formulary Exception Form . . . . . .Benefits and Coverage Clarification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .IUD and Depo-Provera Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Oral Medications for Onychomycosis (Nail Fungus) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Over-The-Counter (OTC) Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Non-Covered Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Brand Name . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Brand and Generic Versions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Sharps Container Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Pharmacy Coordination Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Mandatory Maintenance Drug Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Medications Limited by Provider Specialty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Quantity Level Limits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Mandatory Statin Cost Reduction Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Tablet Splitting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Generic Statins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Step Therapy Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Specialty Drug Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Prescription Drug Benefit Exclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313141516CLEVELAND CLINIC EHP TOTAL CARE DRUG FORMULARYPrescription Drug Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Important Points About the Cleveland Clinic EHP Total Care Drug Formulary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Drug Formulary Medications by Category . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Drug Formulary Medications Alphabetically . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Prior Authorization/Formulary Exception Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .171719253031v
Cleveland Clinic EHP Total Care/SummaCare EPOPrescription Drug BenefitPrescription Drug Benefit AdministrationThe Prescription Drug Benefit is administered through CVS Caremark under the guidance of the EHPPharmacy Coordination Department. You can contact Pharmacy Coordination Monday through Friday,from 8 a.m. to 4:30 p.m., by calling 216-986-1050, option 4 or 1-888-246-6648, option 4. In addition, CVSCaremark has a dedicated, toll-free Customer Service phone number that members can call 24 hours aday, seven days a week: 1-866-804-5876. CVS Caremark Customer Service is also available through e-mailat customerservice@caremark.com.If your CVS Caremark Prescription card is lost or stolen, contact CVS Caremark at the phone number ore-mail address listed above for a replacement card.Members can also go to the CVS Caremark website at www.caremark.com for the following: Prescription Refills for CVS Caremark Mail Service Order Status Pharmacy Locations Benefit Coverage Request Forms Frequently Asked Questions 13 Month Drug History Additional Health InformationWhen you call CVS Caremark or visit their website, please have the following information available: Member’s ID Number Member’s Date of Birth Payment MethodPrescription Drug Benefit Program OverviewThe EHP Total Care/SummaCare EPO Prescription Drug Benefit chart on page 2 of this Handbook summarizesdrug categories such as generic, preferred, non-preferred, and specialty drugs, as well as deductible andout-of- pocket maximum information. Use this Handbook as a resource for information regarding: Options for filling your prescription medications; EHP Prescription Drug Benefit guidelines; Benefits coverage and clarification; Pharmacy Coordination programs; and The EHP Total Care Prescription Formulary.Understanding The FormularyThe medications included in this Handbook are chosen by a group of healthcare professionals known asthe Pharmacy and Therapeutics (P&T) Committee. This Committee reviews and selects FDA-approvedprescription medications for inclusion in the Formulary based on the drug’s safety, effectiveness, qualityand cost to the plan. All medications that have been reviewed but not added to the Formulary or that havenot yet been reviewed by the P&T Committee are considered Non-Formulary.1
EHP Total Care/SummaCare EPO Prescription Drug BenefitAdministered Through CVS CaremarkThe Following Is a Summary Overview of the Prescription Drug Benefit:Tier 1CategoriesAnnual DeductibleTier 2Tier 3Tier rmulary)(Hi-Tech)Generic RxBrands 100 IndividualWaived for generic prescriptions if obtained 300 Familyfrom a Cleveland Clinic Pharmacy15%25%45%20%)(Drugs & Itemsat DiscountedRateNonCovered Drugs& ItemsNoNoEmployee % Co-ins.Employee PaysCleveland Clinic100% of thePharmacies:Discounted Priceup to 90-Day SupplyEmployee % Co-ins.20%30%50%20%Employee PaysCVS Caremark Retail —100% of the30-Day SupplyDiscounted PriceMail Service Program —90-Day SupplyIs there a Minimum orYesYesNoYesNoMaximum to the Rx % 3 Minimum/ 3 Minimum/No Minimum/Co-ins. — Cleveland 50 Maximum 50 Maximum 50 MaximumClinic Pharmaciesper Month Supply per Month Supplyper Month Supply(including Home Delivery)?Is there a MinimumYesYesNoNANoor Maximum to the 5 Minimum/ 5 Minimum/Rx % Co-ins. — Retail? 50 Maximum 50 Maximumper Month Supply per Month SupplyIs there a MinimumYesYesNoYesNoor Maximum to the 15 Minimum/ 15 Minimum/No Minimum/Rx % Co-insurance — 150 Maximum 150 Maximum 300 MaximumCVS Caremark90-Day Supply90-Day Supply90-Day SupplyMail Service Program?Is there an AnnualIndividual 1,500 / Family 4,500NoOut-of-pocket Max?Combined Maximums for Retail and Home Delivery*Specialty Drugs* Life Style DrugsComponents ofGeneric DrugsBrand Name DrugsSee complete list of Benzoyl Peroxide OnlyEach CategorySee page 17AgentsSpecialty DrugsCaverjecton pagesCialis15 and 16Cosmetic AgentsDenavir CreamEdexFertility AgentsLevitraMuseNon-controlled Coughand Cold AgentsOral Allergy MedicationPenlacPropeciaRelenzaTamifluTopical Androgen ProductsViagraWeight Control ProductsXereseZovirax CreamZovirax OintmentPrior AuthorizationRequiredDiabetic Supplies†and AsthmaDelivery Devices†Major Chains‡in the Retail NetworkSee page 8 for List ofPharmaceuticals Requiring Prior AuthorizationCo-insurance 20%NoNot AvailablethroughRx PlanNot AvailablethroughRx PlanNoNoNoNoOver-the-Counter DrugsAlcohol SwabsDME (DurableMedical Equipment)Medical DevicesMedical SuppliesPrescription DrugsBrand and Generic Brandversions of:Adoxa, Doryx, Monodox,Oracea, SolodynOral Contraceptives(Brand Name Products)Proton Pump Inhibitors(Brand Name Products)Certain OTCMedicationsare covered.See page 10NoNANoNAACME, Cleveland Clinic Pharmacies, Costco, CVS, Discount Drug Mart, Giant Eagle,K-Mart, Marc’s, Medicine Shoppe, Rite Aid, Target, Walgreens, Wal-Mart,plus other chains and independent pharmacies.Note: Plan Includes: generic oral contraceptives — covered for Marymount plan participants for clinical appropriateness only.*There are 4 options for obtaining medications in the category listed above. The options are: 1. Cleveland Clinic Pharmacies in Cleveland and Cleveland Clinic Weston Pharmacy2. Cleveland Clinic Home Delivery Pharmacy, 3. Cleveland Clinic Home Infusion Pharmacy (injectables only), and 4. CVS Caremark Specialty Drug Program.†Diabetic Supplies — Insulin and all diabetic supplies covered. Includes: needles purchased separately, test strips, lancets, glucose meters, syringes and injection pens.Asthma Delivery Devices — Includes spacers used with asthma inhalers.‡Members can utilize the CVS Caremark Retail Pharmacy Network for obtaining acute care prescriptions (e.g., single course of antibiotic therapy) and for the first fill of maintenancemedications but must use a Cleveland Clinic Pharmacy or CVS Caremark Mail Service Program for all maintenance medications.2
Take this Handbook with you to all doctor appointments. You are encouraged to share this with your physicianwhen he or she is prescribing your medication to help ensure the most appropriate prescription drug therapyfor your needs. Appropriate and cost-effective use of pharmaceutical therapies can be key to a successfulstrategy for improving individual patient outcomes and containing healthcare costs. The Handbook willassist with both of these goals — maintaining the quality of patient care while helping to keep the cost ofprescription medications affordable.The P&T Committee reviews and updates the Formulary throughout the year. Medications may be addedto or removed from the Formulary during the year. Cleveland Clinic Employee Health Plan Total Care mayadd medications to the Formulary four times a year. Medications may be removed from the Formulary twicea year, once at the start of the benefit year in January and again at mid-year in July.Two resources are available to assist you with determining if the drug prescribed for you is covered underyour program (another reason why you should take the Handbook with you each time you visit your doctor).The two resources are: this Cleveland Clinic EHP Total Care/SummaCare EPO Prescription Drug Benefit andFormulary Handbook and our website. The website version of the Formulary is updated on a regular basisand contains the most current information regarding the Formulary. You can access this website by logginginto www.clevelandclinic.org/ healthplan. The listing of a drug in the Formulary does not guarantee coverageif your contract does not cover that category of drugs (e.g., oral contraceptives, infertility agents).Filling Your PrescriptionsThrough your Prescription Drug Benefit, you have four options for filling your prescription medications.The four options described on the following pages include the Cleveland Clinic Pharmacies; the ClevelandClinic Home Delivery Pharmacy; the CVS Caremark Retail Pharmacy Network; and the CVS Caremark MailService Program.Cleveland Clinic Pharmacies and Home Delivery PharmacyEHP Total Care members receive a lower percentage co-insurance for their prescriptions by using ClevelandClinic Pharmacies in Cleveland and Weston (Option 1), or the Home Delivery Pharmacy (Option 2). In addition,a deductible will not be charged for prescriptions filled at these pharmacies with a generic medication.Call the pharmacy hotline at 216-445-MEDS (6337) for answers to your questions and to obtain pharmacistconsultation services. You can receive up to a 90-day supply of medication at any of the Cleveland ClinicPharmacies in Cleveland, the Cleveland Clinic Home Delivery Pharmacy, or the Weston Pharmacy.Note: By law, the Cleveland Clinic Home Delivery Pharmacy must fill your prescription for the exact quantityof medication prescribed by your doctor, per the 90-day plan limit. For example, a prescription writtenfor a 30-day supply plus two refills does not equal one prescription written for a 90-day supply.You may pick up your prescriptions at any of the locations listed below or you can have your prescription(s)mailed to your home by using the Cleveland Clinic Home Delivery Pharmacy. There is a turnaround timeof up to five business days for all home delivery pharmacy orders. Please Note: You cannot drop off or pickup prescription orders at the Cleveland Clinic Home Delivery Pharmacy. See page 5 for details.Cleveland Clinic Pharmacies — Locations and Hours of Operation Cleveland Clinic Pharmacies On Main Campus:– Euclid Avenue Pharmacy (Parking Garage) . . . . . . . . . . . 216-445-MEDS (6337), Fax: 216-445-6015Toll-free: 1-866-650-MEDS (6337)Direct Dial: 216-636-0760Monday–Friday, 8 a.m.–8 p.m.,Saturday, 9 a.m.–3 p.m.– Crile Pharmacy (A Building) . . . . . . . . . . . . . . . . . . . . . . . . . 216-445-MEDS (6337), Fax: 216-445-7403Toll-free: 1-866-650-MEDS (6337)Direct Dial: 216-636-0761Monday–Friday, 8 a.m.–6 p.m.3
Cleveland Clinic Pharmacies On Main Campus (continued):– Children’s Hospital and . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216-445-MEDS (6337), Fax: 216-444-9514– Surgery Center Pharmacy (P Building) . . . . . . . . . . . . . . . Toll-free: 1-866-650-MEDS (6337)Direct Dial: 216-636-0762Monday–Friday, 9 a.m.–5 p.m.– Taussig Cancer Center Pharmacy (R Building) . . . . . . . . 216-445-MEDS (6337), Fax: 216-445-2172Toll-free: 1-866-650-MEDS (6337)Direct Dial: 216-636-0763Monday–Friday, 9 a.m.–5 p.m. Cleveland Clinic Family Health Centers:– Beachwood Family Health Center . . . . . . . . . . . . . . . . . . . 216-445-MEDS (6337), Fax: 216-839-3271– 26900 Cedar Road, Beachwood, OH 44122 . . . . . . . . . . . . Toll-free: 1-866-650-MEDS (6337)Direct Dial: 216-839-3270Monday–Friday, 8 a.m.–6 p.m.– North Coast Cancer Center Pharmacy . . . . . . . . . . . . . . . Toll-free: 1-866-650-MEDS (6337)– 417 Quarry Lakes Drive, Sandusky, OH 44870 . . . . . . . . Fax: 419-609-2869Direct Dial: 419-609-2845Monday–Friday, 9 a.m.–4 p.m.– Richard E. Jacobs Health Center . . . . . . . . . . . . . . . . . . . . 216-445-MEDS (6337), Fax: 440-965-4109– 33100 Cleveland Clinic Boulevard, Avon, OH 44011 . . . Toll-free: 1-866-650-MEDS (6337)Direct Dial: 440-695-4100Monday–Friday, 8 a.m.–6 p.m.– Stephanie Tubbs Jones Health Center . . . . . . . . . . . . . . . . . 216-445-MEDS (6337), Fax: 216-767-4128– 13944 Euclid Avenue, East Cleveland, OH 44112 . . . . . . Toll-free: 1-866-650-MEDS (6337)Direct Dial: 216-767-4200Monday–Friday, 9 a.m.–5 p.m.– Strongsville Family Health Center . . . . . . . . . . . . . . . . . . . 216-445-MEDS (6337), Fax: 440-878-3148– 16761 Southpark Center, Strongsville, OH 44136 . . . . . . Toll-free: 1-866-650-MEDS (6337)Direct Dial: 440-878-3125Monday–Friday, 8 a.m.–6 p.m.– Twinsburg Health Center Pharmacy . . . . . . . . . . . . . . . . . 216-445-MEDS (6337), Fax: 330-888-4105– 8701 Darrow Road, Twinsburg, OH 44087 . . . . . . . . . . . . Toll-free: 1-866-650-MEDS (6337)Direct Dial: 330-888-4200Monday–Friday, 8 a.m.–6 p.m.– Willoughby Family Health Center . . . . . . . . . . . . . . . . . . . 216-445-MEDS (6337), Fax: 440-516-8629– 2570 SOM Center Road, Willoughby, OH 44094 . . . . . . . Toll-free: 1-866-650-MEDS (6337)Direct Dial: 440-516-8620Monday–Friday, 8 a.m.–6 p.m. Cleveland Clinic Regional Hospital Locations:– Fairview Health Center Pharmacy . . . . . . . . . . . . . . . . . . . 216-445-MEDS (6337), Fax: 216-476-9905– 18099 Lorain Road, Cleveland, OH 44111 . . . . . . . . . . . . . Toll-free: 1-866-650-MEDS (6337)Direct Dial: 216-476-7119Monday–Friday, 8 a.m.–6 p.m.– Marymount Family Pharmacy . . . . . . . . . . . . . . . . . . . . . . . 216-445-MEDS (6337), Fax: 216-587-8844– 12000 McCracken Road, Suite 151 . . . . . . . . . . . . . . . . . . . Toll-free: 1-866-650-MEDS (6337)– Garfield Heights, OH 44125 . . . . . . . . . . . . . . . . . . . . . . . . . Direct Dial: 216-587-8822. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Monday–Friday, 8 a.m.–6 p.m.– Weston Pharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 954-659-MEDS (6337), Fax: 954-659-6338– 2950 Cleveland Clinic Blvd., Weston, FL 33331 . . . . . . . . Toll-free: 1-866-2WESTON (293-7866)Direct Dial: 954-659-6337Monday-Friday, 9 a.m.–5:30 p.m.4
Free Shipping Mail Order by Cleveland Clinic:– Cleveland Clinic Home Delivery Pharmacy . . . . . . . . . . . Direct Dial: 216-328-6075Toll-free: 1-855-276-0885Monday–Friday, 7 a.m.–6 p.m.Cleveland Clinic Home Delivery Pharmacy Ordering InstructionsThe Home Delivery Pharmacy is designed to ship medication directly to your home with no shipping charge.By using the Home Delivery Pharmacy, members receive a lower percentage co-insurance for their medicationscompared to the CVS Caremark Retail Pharmacy Network and can enjoy the convenience of having 90-daysupplies of their maintenance medications delivered directly to their home. Here’s how you can getstarted:1. Go to the MyRefills website at https://myrefills.clevelandclinic.net to set up your account, change your billinginformation and shipping address, or to check on the status of your order.You may also set up your account by completing a Home Delivery Service Processing Form. You can callthe Home Delivery Pharmacy at 216-328-6075 or 1-855-276-0855 to have this form mailed or faxed toyou. Fill out a Home Delivery Service Processing Form to indicate payment and shipping informationfor you and your dependents. This information will be kept on file to avoid filling out a form every timeyou place a prescription order.Note: You will have to set up your Home Delivery account before the Home Delivery Pharmacy can processand ship your order. In addition, each member that wishes to use the Home Delivery Pharmacy needsa separate account.2. The Home Delivery Pharmacy receives prescription orders in the following ways: Called in by your physician to 1-866-650-MEDS (6337), option 2 Faxed in by your physician to 216-328-6076 e-Scripted by your physician via EPIC (CCF Home Delivery Pharmacy) Requested online through https://myrefills.clevelandclinic.net If you have a hard copy of a new prescription, by law, you cannot fax the prescription to the HomeDelivery Pharmacy. Please mail the prescription to:Home Delivery ServiceP.O. Box 25220Garfield Heights, OH 44125-0220 If you are transferring a prescription from a pharmacy other than a Cleveland Clinic Pharmacy, pleasecontact the Home Delivery Pharmacy at 216-328-6075 for assistance.Please note that members cannot drop off or pick up their orders at the Home Delivery Pharmacy.Orders will be shipped free of charge to the address you designate.The Cleveland Clinic Home Delivery Pharmacy is available Monday–Friday from 7:00 a.m. to 6:00 p.m.Please allow five business days from the time they receive your prescription order(s) for delivery.Please call 216-328-6075 for questions or additional information on the Cleveland Clinic Home DeliveryService.5
Processing FormEmployee Health Plan Total Care/Cleveland Clinic PharmaciesHome Delivery Service: Processing FormDate: / /E-mail:Employee Name:Prescription Insurance ID No.:Employee ID Badge No. (Required):Badge Encoded No.: (6 digit number on back of ID badge)Patient Name (If different):Patient Medical Record No.:Patient Date of Birth: / /Primary Shipping Address:Patient p:Contact Phone No.:Alternate Phone No.:List prescriptions being filled (name or Rx number):1.2.3.*If these are prescriptions from another pharmacy, please indicatethe following:Name and Phone No. of Pharmacy:Rx Number’s or Name(s) of Medications:Is Generic OK? Yes No, Brand Name is requested:ELPMSADrug Allergies (Please list):Payment Method: FSA Card (PayFlex): Please also indicate an alternate formof payment should there be an insufficient balance. If PayFlexis your primary choice for payment, we will need a creditcard to process any balance in excess of the PayFlex card. Credit Card (Visa/Mastercard/Discover/AMEX)FSA Card No.:Credit Card No.:Expiration Date:Expiration Date:Signature:Signature: Payroll DeductionI hereby authorize Cleveland Clinic Pharmacies to enroll me in the Payroll Deduction for Pharmacy Purchases Program. I understandthat my badge is the property of the Cleveland Clinic Foundation and must be returned to the ID badge Department upon terminationof employment or upon request by the Cleveland Clinic Foundation. I further understand that I will be responsible for all charges madewith this badge and I hereby authorize those charges to be deducted from my paycheck. Charges made during a payroll period will bereflected as “Pharmacy” on the corresponding paycheck stub. Furthermore, I agree to protect this badge from unauthorized use andto pay Cleveland Clinic Pharmacies any outstanding balance upon termination of my employment or withdrawal from this program.The information above will be held confidential. I recognize that any unauthorized and/or illegal use of any badge is classified as amajor infraction and will be grounds for disciplinary action in accordance with CCF Policy 121.I have read the above information and agree to all of the above and authorize use of one time payroll deduction for the entire amount due.Signature: Date: / /Use: 1 Pay Cycle 2 Pay CyclesAt what amount would you like us to contact you before processing your order? Phone: 216-328-6075Fax: 216-328-6076Mail to: Home Delivery ServiceP.O. Box 25220Garfield Heights, OH 44125-0220All hard copy prescriptions must be mailed with this formHome Delivery turnaround time is five business days from receipt of this form and your prescription(s)For faster service of your refills, please call 216-445-MEDS (6337) or 1-866-650-6337 to use our automated refill system.*Note: Prescriptions transferred from a retail pharmacy can only be filled for a 30 day supply.*Note: If you would like to order a 90 day supply, have your physician call in or write a new prescription to be filled for a 90 day supply.Advantages of Utilizing theCleveland Clinic Pharmacies and Home Delivery Pharmacy Lower cost: You will pay less for prescription co-insurance. In addition, your deductible will be waived forprescriptions filled with a generic medication at these pharmacies. Convenience: You may request a 90-day supply of medications at any Cleveland Clinic Pharmacy.Note: The prescription must be written for a 90-day supply. Peace of mind: You will have access to a toll-free hotline number for questions and pharmacist consultationservices during regular business hours.CVS Caremark Retail Pharmacy NetworkMembers have the option of picking up acute care prescriptions (such as antibiotic therapy or pain medication)or the first fill of any maintenance medication (limited to a 30-day supply) at any neighborhood pharmacythat participates in the CVS Caremark Retail Pharmacy Network. Refills of maintenance medications must beobtained through one of the three options identified in the Mandatory Maintenance Drug Program sectionon page 11. Please see the Prescription Drug Benefit chart on page 2 for major pharmacy chains in the RetailNetwork. CVS Caremark offers over 55,000 participating retail pharmacies in their national pharmacy network.A complete list of these pharmacies can be found
Welcome to the Cleveland Clinic Employee Health Plan (EHP) Total Care/ SummaCare EPO Prescription Drug Benefit Program. As a Cleveland Clinic or Regional hospital employee, you have access to a comprehensive prescription drug benefit. To help you understand the benefits available to you under this
