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Tcoe.org

Self-Insured Schools of California
Prescription Program – SETTC
Effective October 1, 2009

Co-payments – Retail
Members can receive up to a 30-day supply of prescription drugs through any of American
Health Care’s contracted pharmacies.
EMPLOYEES and DEPENDENTS
Generic Drugs $3.00
Brand-Name Drugs $15.00
Costco Program: able to receive generics from Costco at a $0.00
co-payment, with the exception of some narcotics and cough medicines

Co-payments – Mail Order
Members can receive up to a 90-day supply of maintenance medications through American
Health Care’s mail-order pharmacy—informedMail. Please contact AHC at (800) 872-8276 for
further information.
EMPLOYEES and DEPENDENTS
Generic Drugs $3.00
Brand-Name Drugs $35.00
2217 Plaza Drive, Suite 100 ▪ Rocklin, CA 95765 ▪ Member Services (800) 872-8276 ▪ Office (916) 773-7227 Fax (916) 773-7210 ▪ TDD/TTY: (866) 571-6106 or (916) 960-0161
Additional Provisions
• If a brand-name drug is dispensed when there is an equivalent generic available, member
may be subject to paying the difference in cost between the brand-name and generic plus
the generic co-payment.
• Diabetic LANCETS, SYRINGES, and TEST STRIPS will be covered at your generic co-payment.
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. Please contact AHC at (800) 872-7276 or via the internet at
with any questions you may have regarding your pharmacy benefit. A member services
representative will be happy to help you. The team at AHC looks forward to meeting all of your prescription benefit needs.

Please note that this list may not be all-inclusive.

Cosmetic only indications - Photo-aged skin products ( Renova® for patients aged 36 and over prior authorization required), Injectable cosmetics (Botox) Dermatology - Depigmentation products used for skin conditions requiring a bleaching agent, Accutane (covered up to 20 weeks upon prior authorization approval only), Retin-A®, and Avita® (for patients aged 36 and over prior authorization required for cream only; gel excluded) Contraception - (Depo-Provera®, Lunelle®, Norplant®, Diaphragms, IUDs) Weight Management – All (prior authorization required) Self-Injectables -other than insulin Serums, Toxoids, Vaccines - All Vitamins –oral- All (exception: oral Calcitriol / Rocaltrol, prenatal agents used in pregnancy (must contain legend medication), multi-vitamins with fluoride, which are covered benefit) Fluoride products – All (Dental – paste, gel, mouthwash; Pediatric – Luride, Poly-Vi-Flor) Smoking Cessation Products – All Non-legend medications (OTC) – All (Excluding: Prilosec OTC®, Omeprazole OTC which are covered benefit) Antihistamines – All (Excluding: Claritin OTC®, Claritin-D OTC®, Zyrtec OTC®, Zyrtec-D OTC®, Cetirizine OTC, Cetirizine-D OTC, which are a covered benefit) Proton Pump Inhibitors (PPI’s) - All (Exception: Aciphex®, Prevacid®, Protonix® require prior authorization) Diabetic Supplies – (Blood Glucose monitors and kits (Glucose/Glucose & Ketone Combination), Blood Glucose Calibration Solutions, Swabs) Durable Medical Equipment – All (including: Respiratory therapy supplies (Aerochamber, Spacers, Peak Flow Meters, Ostomy Supplies) Prior authorization required – Wellbutrin XL®, Effexor XR®, Cymbalta®, migraine medications: all (excluding: Sumatriptan (generic Imitrex) and Relpax), osteoporosis: all (excluding: Alendronate (generic Fosamax®), intranasal agents: all (excluding: Fluticasone (generic Flonase®) and Nasonex® • Other - lost, stolen or misplaced medication 2217 Plaza Drive, Suite 100 ▪ Rocklin, CA 95765 ▪ Member Services (800) 872-8276 ▪ Office (916) 773-7227 Fax (916) 773-7210 ▪ TDD/TTY: (866) 571-6106 or (916) 960-0161

Source: http://www.tcoe.org/HR/EmployeeInfo/Benefits/09_RxSummary_Cert.pdf

News_nbt0408.indd

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Doi:10.1016/j.jen.2005.02.012

Authors: Janna Deason, RN, MSN, CNS, FNP, CEN, BrendaHope, RN, MSNA 23-year-old obese man presents to the emergencyJanna Deason and Brenda Hope are staff nurses in the emergencydepartment of McKee Medical Center, Loveland, Colo. department (ED) with a chief complaint of substernalFor correspondence, write: Janna Deason, 200 N Boise Ave, Loveland,chest pressure and dizziness for 2O hours. The

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