The medical plans all offer prescription drug coverage. Under the HealthPlus and Standard Options, the Prescription Drug Program is administered by Express Scripts (ESI).
In general, the program offers prescription drug benefits two ways:
- For short-term prescriptions, you must fill your prescription at any Express Scripts network retail pharmacy, unless one is not available in the area.
- For longer term maintenance prescriptions, you must use the home delivery service.
When you participate in either option, you will receive a separate ESI prescription drug ID card. Each time you fill a prescription at an ESI network retail pharmacy, simply show your ID card so the pharmacist knows you are covered under the program.
- If you are a participant in the HealthPlus Option, there is no separate prescription drug deductible. You only pay your applicable prescription drug copay.
- If you are a participant in the Standard Option, you must meet the separate prescription drug deductible before the plan pays a benefit. Once you meet the separate prescription drug deductible, you will pay a copay for generic drugs, or the applicable coinsurance for preferred or non-preferred brand name drugs.
When you use home delivery, you must submit information to ESI. (See Home delivery program for more information.)
Prescription drugs usually fall into one of two basic categories — generic and brand name. Regardless of where you choose to fill your prescription, the program covers three levels of medications: generic drugs, brand name preferred drugs and brand name non-preferred drugs.
- Generic drugs have the same active ingredients as brand name drugs and are subject to the same Food and Drug Administration (FDA) standards for quality, strength and purity as their brand name counterparts. Not all brand name drugs have generic equivalents. Typically, your pharmacist will fill your prescription with a generic drug, if available, unless you or your doctor specify otherwise.
- Brand name drugs are drugs patented by the FDA and subject to an exclusivity agreement, which allows the company to be the sole manufacturer of the drug for a certain number of years. Brand name drugs include preferred drugs and non-preferred drugs.
- Preferred drugs are drugs that Express Scripts considers preferred choices, based on their effectiveness and cost, and are on ESI's formulary drug list.
- Non-preferred drugs are those that are not on ESI's formulary drug list.
A formulary is a list of recommended prescription medications that is created, reviewed and continually updated by a team of physicians and pharmacists. The Express Scripts formulary contains a wide range of generic and brand name preferred products that have been approved by the Food and Drug Administration (FDA). The formulary applies to medications that are dispensed in a retail pharmacy or mail service setting. The formulary is developed and maintained by Express Scripts and is available online or a paper copy may be requested. Formulary designations may change as new clinical information becomes available.
If a prescription drug does not have a generic equivalent available, you will be charged the brand name copay (preferred or non-preferred, depending on the drug). Please note that the information on the formulary drug list is not BP-specific, and not all of the preferred drugs covered may be listed nor does BP cover all the drugs that may be listed. If you do not see your drug listed, contact Express Scripts for coverage information.
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|
|
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| Prescription Drug |
Retail |
Home Delivery |
Retail |
Home Delivery |
| Rx Deductible |
No separate Rx deductible |
$75/person; $225/family |
| |
Copay*/Coinsurance |
| Generic |
$5 copay |
$12 copay |
$5 copay |
$12 copay |
| Brand name (preferred) |
$25 copay |
$65 copay |
20%; $25 minimum; $50 maximum |
20%; $65 minimum; $130 maximum |
| Brand name (non-preferred) |
$45 copay |
$125 copay |
40%; $45 minimum; $100 maximum |
40%; $125 minimum; $250 maximum |
| Brand name (non-preferred) when generic is available |
$5 copay plus the difference in cost between the brand name and the generic |
$125 copay |
$5 copay plus the difference in cost between the brand name and the generic |
40%; $125 minimum; $250 maximum |
* You always pay the lesser of the actual cost of your prescription or the copay. All brand name non-sedating and low-sedating antihistamines — even if on the formulary drug list — are subject to the brand name non-preferred drug copay.
Prescription drugs are covered (subject to plan exclusions and limitations) under the Prescription Drug Program if they:
- Require a prescription for dispensing;
- Are FDA indicated for an approved diagnosis;
- Are medically necessary; and
- Are not experimental in nature.
If you participate in a Standard Option and have not met the plan year prescription drug deductible, you pay 100% of the negotiated cost of the medication (if applicable) at a network pharmacy — or the billed charges if a network pharmacy is not available — until the deductible is met. After that, you pay only the applicable copay or coinsurance.
Expenses that are not applied to the Prescription Drug Program deductible include:
- Copays.
- Prescriptions filled at a retail pharmacy after the two-fill limit on maintenance medication is reached.
- Prescriptions filled at a non-network pharmacy when an ESI network pharmacy is available.
- Prescriptions not covered under the Prescription Drug Program.
Inpatient care and your prescription benefit
Prescription drugs received while you are an inpatient at an extended care facility/skilled nursing facility are payable under the Prescription Drug Program (and not under the medical coverage provisions of the plan). Because you have no control over whether a network pharmacy is used, coverage is provided even when the prescription drugs are obtained from a non-network pharmacy. Whether a network or non-network pharmacy is used, you may need to pay for the prescription drug up front and then file a claim for reimbursement.
Publication date: April 2012