Caterpillar Closed Formulary

Welcome to the Caterpillar Drug Formulary

This formulary applies to active Employees and certain Retirees that are covered by the prescription drug benefit provisions of the Caterpillar Inc. Employee Health, Life and Disability Benefit Program, the Caterpillar Inc. Retiree Benefit Program, the Caterpillar Inc. Group Insurance Plan A, and the Caterpillar Inc. Group Insurance Plan B.

What is a Formulary?

A formulary is a list of medications that are covered by the plan. The formulary is reviewed quarterly for possible additions and deletions. New generics for a covered brand name medication may be covered between quarterly updates based on plan approval and availability. Use of generic medication is required when generic is available.

The formulary is developed and maintained by a team of Physicians and Pharmacists based on product safety, efficacy, and clinical integrity. If a medication or product that has been prescribed for you or your covered dependents is not on the formulary, it is not a covered benefit. You will pay 100% of the full retail cost. You may wish to speak to your doctor for an alternative option.

How to Search For Drugs

• Use the alphabetical list to search by the first letter of your medication
• Search by typing part of the generic or brand name of the medication
• Search by selecting the therapeutic class of the medication you are looking for

Plan Design

Co-pay / Co-insurance Tiers

This is the amount you will pay for medications covered under the plan after meeting your deductible (if applicable). Amounts are based on a 30-day supply unless otherwise noted.

Drug Tier	In-Network* Walmart, Kroger, Walgreens, CPRxN	Out-of-Network (All other Pharmacies)	Mail Order/ Home Delivery*** (90-day Supply)
Tier 0	$0	$25	$0
Tier 1	$5 Walmart/ Kroger $10 Walgreens/ CPRxN	$25	$30
Tier 2	20% co-insurance Min $35 | Max $70	30% co-insurance Min $60 | Max $130	20% co-insurance Min $105 | Max $210
Tier 3	50% co-insurance Min $85 | Max $135	50% co-insurance Min $160 | Max $260	50% co-insurance Min $255 | Max $405
Tier 4	50% co-insurance Min $110 | Max $210	50% co-insurance Min $160 | Max $260	Not offered

*Includes affiliates of Walmart, Kroger, and Walgreens. Also includes Prime Therapeutic Pharmacy for Specialty Medications
**Walgreens Mail Service (formerly Alliance Rx Walgreens Pharmacy)

Preventive (PR)

If you are enrolled in a Consumer-Directed Health Plan Option (CDHP), you may be required to pay the full cost of your medication until you reach your deductible. Please review the Consumer-Directed Health Plan Preventive Drug List on benefits.cat.com for those drugs that bypass the deductible. These drugs also can be identified by the label of ‘PR’ within the formulary list.

Diabetic Supplies & Insulins

The following over-the-counter (OTC) diabetic supplies and Insulins are covered under the prescription drug benefit with a valid prescription from your provider.

Contour Next and FreeStyle test strips are preferred. Your plan offers a Free Meter Program if you switch to Contour Next or FreeStyle Test Strips.

• Have your pharmacy process your Ascensia Diabetes Contour meter through RxBIN# 018844, PCN# 3F, Group ID# MGDCARE, ID# CNMC7246982. OR Call 1-800-401-8440 and mention ID Code for your BDC-PTS free meter (limitations or restrictions may apply).
• Have your pharmacy process your FreeStyle meter prescription through RxBIN# 610020, Group# 99992432, ID# ERXACTMETER.

Product Description	Tier	Limits & Restrictions
Insulin Syringes	1	PR-Preventive Medication
Lancets	1	PR-Preventive Medication QPD-Quantity Per Day
Glucose Meters
Contour	2	PR-Preventive Medication QL-Quantity Limit
FreeStyle	2	PR-Preventive Medication QL-Quantity Limit
All Other Brands	3	PR-Preventive Medication QL-Quantity Limit
Glucose Test Strips
Contour Next	1	PR-Preventive Medication QPD-Quantity Per Day
FreeStyle	1	PR-Preventive Medication QPD-Quantity Per Day
All Other Brands	3	PR-Preventive Medication QPD-Quantity Per Day
Insulins
HUMULIN 70-30 VIALS HUMULIN N VIALS HUMULIN R VIALS NOVOLIN N VIALS NOVOLIN R VIALS NOVOLIN 70-30 VIALS	0	PR-Preventive Medication

Health Care Reform (HCR)

The list includes preventive care medications covered in accordance with the Patient Protection and Affordable Care Act (ACA), as modified by the Healthcare and Education Reconciliation Act of 2010. Certain preventive care medications are covered at 100% by the plan if you use an In-Network Pharmacy. If you use an Out-of-Network Pharmacy, you will be subject to the applicable co-pay or co-insurance. These medications are labeled as ‘HCR’ on this formulary listing. For additional information on preventive care medications covered by the plan, visit: healthcare.gov/center/regulations/prevention.html or uspreventiveservicestaskforce.org

Additional Information

Please refer to your summary plan description (SPD) provided at CatHealthEnrollment.bswift.com

If you have questions about your prescription drug coverage, you can also call Prime Therapeutics Customer Service toll-free at 1-877-228-7909 24 hours a day, 7 days a week.

The information regarding alternatives is not intended and should not be construed, in any way, as medical advice, opinion, diagnosis or as advice about the treatment of any specific medical condition. You should consult with your physician regarding your particular health needs and whether any of the alternative treatments are right for you. In the event that the content of this document or any representations made by any person regarding the plan conflict with or are inconsistent with the provisions of the plan document, the provisions of the plan document are controlling. To the fullest extent permitted by law, Caterpillar reserves the right to amend, modify, suspend, replace or terminate any of its plans, policies or programs, in whole or in part, at any time and for any reason, by appropriate company action.

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