Balancing Point Center for Wellness WOMEN’S FERTILITY QUESTIONNAIRE Name: ___________________________________________ Date: _______________________ 1.Basic Information a. Address: ____________________________________________________________________________________________ 2. Menstrual History 3. Gynecologic History a. At what age did you begin your menses? ________a. D
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Ot5900b.qxdSISC CO-PAYMENT REFERENCE GUIDE
Medco manages your prescription drug benefit at the request of SISC. Your plan gives you
the option of getting your covered medications through the Medco Pharmacy® mail-order
service or at a participating retail pharmacy.
The chart below provides a summary of your prescription drug benefit co-payments. When you use a participating
When you use the
Type of medication
retail pharmacy, you pay:
Medco Pharmacy, you pay:
$200 single/$500 family
$200 single/$500 family
Please note: Any amount of deductible satisfied during the 4th quarter of the year will carry over to the following year. *A generic drug will always be dispensed if one is available. If you purchase a brand-name drugwhen a generic alternative is available, you will pay the generic co-payment plus the difference incost between the brand and the generic, even if your doctor writes “dispense as written” (DAW) onthe prescription. When you visit a participating retail pharmacy and present your member ID card, you will
pay the applicable cost share and receive up to a 30-day supply of the prescribed drug. For
medication you take on an ongoing basis, using the Medco Pharmacy offers you convenience
and potential cost savings. You can get more information about the Medco Pharmacy
mail-order service by calling 1 800 MEDCO-MAIL (1 800 633-2662).
If you have Internet access, you can visit us online at www.medco.com. After registering,
you can access information about your benefits, as well as health and wellness resources.
You may also contact Member Services toll-free at 1 800 987-5241. Medco looks forward to
meeting all of your prescription benefit needs.
Medications that are not covered by your drug plan
Listed below are medications and medication categories that are not covered under your
SISC drug plan. The list may not reflect all non-covered drugs and may be subject to change.
To confirm whether a prescription drug you need to take is covered or to check the cost of a
medication, visit www.medco.com and click “Price a medication.” (If you’re a first-time
visitor to the site, please take a moment to register. You’ll need your member ID number and
the number from a recent prescription.) You can also get coverage and pricing information
by calling Medco Member Services toll-free at 1 800 987-5241.
Please note that this list may not be all-inclusive.
• Anti-wrinkle agents (Renova®, Retin-A®, and Avita® for patients aged 36 and over)• Experimental drugs• Fertility medications (Follistim®, Gonal-f ®, Clomid®, and Repronex®)• Influenza treatments (for example, Relenza® and Tamiflu®)• Medications labeled “Caution—limited by federal law to investigational use”• Over-the-counter medications • Pigmenting/depigmenting agents (hydroquinone, Eldopaque® and Eldoquin®)• Hair growth and hair removal agents (Propecia® and Vaniqa®)• Smoking-cessation agents (Nicorette®, Zyban®, Chantix™, and all nicotine patches)• Vitamins (except prescription strengths of prenatal vitamins, hematinics, Rocaltrol® • Brand non-sedating antihistamines (for example, Clarinex®, Clarinex-D®, Xyzal®) (See the reverse side for your plan’s co-payment reference guide.)
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