Prescription drug coverage

The medical plans all offer prescription drug coverage. Under the HealthPlus, Standard and Health+Savings Options, the Prescription Drug Program is administered by Express Scripts (ESI).

In general, the program offers prescription drug benefits in two ways:

  • For short-term prescriptions, you must fill your prescription at any Express Scripts network retail pharmacy, unless one is not available in your 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.
  • If you are a participant in the Health+Savings Option, there is no separate prescription drug deductible. You pay your applicable prescription drug copay after you satisfy the medical plan deductible.

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.

The ESI formulary excludes certain drugs from coverage. However, ESI provides preferred alternatives to all non-covered drugs that achieve similar results.

Excluded products are not covered by the plan. An exception process exists for participants, but you will need a qualified medical necessity, which must be evidenced in writing from your doctor. If you believe you are in need of this exception following a denial, you will be provided a form to appeal this decision along with the denial. If you have any questions about this process, please contact Express Scripts at the number listed later in this document or the BP HR & Benefits Center.

The Prescription Drug Program includes a Generic Preferred Program, which is designed to encourage use of generic medications to lower prescription drug costs.

If a generic equivalent drug is available and you choose the brand name medication rather than the generic option, you will pay the brand name copay/coinsurance plus the difference between the cost of the brand name medication and the equivalent generic medication. The additional cost applies regardless of whether your doctor prescribes a brand name drug. Note: For the Health+Savings Option, you will still be required to satisfy the medical deductible first before you pay your applicable prescription drug copay.

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.

Drug utilization management

The Prescription Drug program also includes a Drug Utilization Management Program, designed to help you make more cost-effective drug choices. The program has three components: prior authorization, step therapy and drug quantity management:

Prior authorization

Prior authorization is a program that monitors certain prescription drugs and their costs to get you the medication you require while reducing costs.  If you’re prescribed a certain medication, that drug may need a “prior authorization.” This program helps to make sure you’re getting a prescription that is covered by your pharmacy benefit.

Your own medical professionals are consulted, since your plan will cover it only when your doctor prescribes it to treat a medical condition that will promote your health and wellness. When your pharmacist tells you that your prescription needs a prior authorization, it simply means that more information is needed to see if your plan covers the drug.  Only your physician can provide this information and request a prior authorization.
 
Step therapy

Step therapy is designed for people who regularly take prescription drugs to treat ongoing medical conditions, such as arthritis, asthma or high blood pressure.

How does step therapy work? Prescription medications are grouped into categories:
  • Step 1 medications are generic drugs that have been approved by the U.S. Food & Drug Administration (FDA). This program will look to see if these medications are prescribed first, since many generics can provide the same health benefits as more-expensive medications but at a lower cost.
  • Step 2 medications are brand-name drugs such as those you see advertised on TV. They’re approved for coverage only if a Step 1 medication doesn’t work for you. Step 2 medications almost always cost more.
What if your doctor prescribes a Step 2 medication? Ask if a generic (Step 1) medication may be right for you. Please share your formulary – the list of prescription drugs covered by your plan – with your doctor. The pharmacy will not automatically change your prescription; your doctor must write a new prescription for you to change from a Step 2 medication to a Step 1 medication, or indicate that a generic can be substituted for the brand name drug, as many providers already do. If a Step 1 medication is not a good choice for you, your doctor can request prior authorization from Express Scripts to determine if a Step 2 medication will be covered by your plan.

Drug quantity management

Certain drugs will have quantity limits in order to help promote economical use. The program follows guidelines developed by the U.S. Food and Drug Administration (FDA).

Here is how the program works at the pharmacy:
  • When your pharmacist attempts to fill your prescription, the pharmacist will get a message about any applicable quantity limitations for the quantity prescribed. This could mean:
    • You are getting your refill too soon; that is, you should still have medicine left from your last supply. In this case, ask your pharmacist when it will be time to get a refill; or
    • Your physician wrote you a prescription for a quantity larger than the plan covers.
  • If the quantity on your prescription is more than the plan allows, you can:
    • Have your pharmacist fill your prescription as written, for the amount the plan covers and pay the appropriate copayment or coinsurance amount. If you would like the additional quantity prescribed, you have the option to pay the full price.
    • Ask your pharmacist to call your physician. They can discuss changing your prescription to a higher strength or different quantity, if available.
    • Ask your pharmacist to contact your physician about getting a “prior authorization.” That is, your physician can call Express Scripts to request that you receive the original quantity and strength he/she prescribed. Express Scripts’ prior authorization is available to your physician, 24 hours a day, seven days a week, so a determination can be made right away.
For home delivery, the Express Scripts Home Delivery Pharmacy will try to contact your physician to discuss the prior authorization review process. If the Express Scripts Home Delivery Pharmacy does not hear back from your physician within two days, they will fill your prescription for the quantity covered by the plan. If a higher strength is not available, or the plan does not provide a prior authorization for a higher quantity, the Home Delivery Pharmacy can fill your prescription for the quantity that the plan covers. For more information about quantity limits under the plan, visit www.express-scripts.com or call Express Scripts.

You should review the medications prescribed to you with your doctor and discuss whether a generic medication may be right for you. Should your doctor determine a generic medication is not right for you, an exception process exists when you have a qualified medical necessity and at the request of your doctor. The program procedures typically take place with your doctor before you fill your prescription. You should inform your doctor of any required steps at the time he or she recommends any prescriptions to you.

Prescription drug summary chart 

 
 
HealthPlus Option
Standard Option
Health+Savings Option
Prescription Drug Retaila Home Delivery Retaila Home Delivery Retaila Home Delivery
Rx Deductible No separate Rx deductible $75/person; $225/family No separate Rx deductible; Rx subject to medical plan deductible
  Copayb/Coinsurance
Generic $5 copay $12 copay $5 copay $12 copay Deductible, then 100% after $5 copay, except for certain generic preventive covered at 100% with no copay or deductible Deductible, then 100% after $12 copay, except for certain generic preventive covered at 100% with no copay or deductible
Brand name (preferred) $25 copay $65 copay 20%; $25 minimum; $50 maximum 20%; $65 minimum; $130 maximum Deductible, then 100% after $25 copay Deductible, then 100% after $65 copay
Brand name (non-preferred) $45 copay $125 copay 40%; $45 minimum; $100 maximum 40%; $125 minimum; $250 maximum Deductible, then 100% after $45 copay Deductible, then 100% after $125 copay
Brand name (when generic is available)c Brand name copay plus the difference in cost between the brand name and the equivalent generic Brand name coinsurance plus the difference in cost between the brand name and the equivalent generic Deductible, then brand name copay plus the difference in cost between the brand name and the equivalent generic

a Prescriptions purchased at an out-of-network pharmacy are covered only if a network pharmacy is not available.

b You always pay the lesser of the actual cost of your prescription or the copay.

c When paying the brand name copay/coinsurance plus the difference in cost between the brand name and equivalent generic, your cost will not exceed the negotiated cost of the brand name medication.

Covered prescription drug expenses

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 the 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 separate Standard Option 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 (Out-of-network facilities)

Prescription drugs to be taken home after you are an inpatient at an out-of-network 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.

Prescriptions covered without deductibles or copays

The following prescriptions are 100% covered without a need to pay a medical or prescription drug deductible or pay any copays:

  • FDA-approved women’s contraception.
  • Certain generic preventive prescriptions (applies to the Health+Savings Options only).
  • Generic and over-the-counter medications that are prescribed for use in cleansing the bowel as a preparation for screening colonoscopy.

 

Publication date: April 2019

 

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