Egyptian Area Schools Employee Benefit Trust

Prescription Drug Program – Step Therapy

Egyptian Trust’s prescription drug program includes a Step Therapy program. The program identifies certain drugs as having a less costly, equally therapeutic equivalent drug the member is required to try prior to filling a more costlyStep Two drug. This is a cost savings measure for both the member and the Egyptian Trust. However, new employer districts are “grandfathered” into the plan meaning that if you or your covered dependent was taking a Step Therapy drug within 130 days prior to your enrollment into the Egyptian Plan, you may continue to take that drug. In order to “grandfather” any drugs you are currently prescribed that meet the definition of a Step Two drug please provide us with the related information for all drugs currently being taken by you or others in your household that will be covered through the Egyptian Trust in order for us to override our system to allow coverage for such drugs.

Employee Name / Employee Social
Security Number / Patient Name / Drug Name / Dosage and/orNDC number

Keep in mind, this will only apply to those drugs you were taking within 130 days prior to your Employer’s entrance into the Egyptian Trust and should a physician prescribe a new drug that is a Step Therapy drug – you will have to gothroughthenormalprocessof either a)tryingaStep1drugorb)payingfullpricefortheprescribeddrug.ThisStepTherapylistissubjecttochangethroughouttheyearsotherecouldbesituationswhereapersonwillbeturneddownforanewStepTherapydrug(inwhichcasetheirphysicianorpharmacyshould contact the Caremark Prior Authorization Department 800-294-5979). StepTherapydrugsareidentifiedon the attached list.Youshouldfeelfreetosharethislistwithyourphysiciansotheyareabletoprescribeproperbutpossiblylesscostlydrug sfortreatmentofyourcondition.

Tothebestofmybeliefandknowledge,theinformationIhaveprovidedonthisformiscompleteandcorrect,andthatnomaterialinformationhasbeenwithheldoromitted.Itisillegalforanypersontoknowinglyandwithintenttoinjure,defraud,ordeceiveanyinsurer,fileastatementofclaimoranapplicationcontaininganyfalse,incomplete,ormisleadinginformation.

Employer: Quincy Public Schools Group Number: 13416

Employee/Parent/GuardianSignature:______

Date:______

Please return this form via fax to 888-525-2799