Q. Does the Plan cover outpatient prescription drugs?
A. Yes, but only if you are not enrolled in Medicare Part D or a Medicare Part C plan that provides a Medicare prescription drug benefit. The Plan's prescription drug benefits offer cost-saving ways to buy outpatient prescription drugs:
- A network of local participating retail pharmacies for short-term prescriptions.
- Express Scripts Pharmacy, the mail-order service for long-term or maintenance prescriptions.
- Express Scripts Specialty Pharmacy.
No deductible is required.
Note: Prescription medications, including injections, billed by and provided in a hospital or a doctor's office are not covered under the prescription drug program but may be covered medical expenses under the Medicare Supplement Plan. Medications billed to you by a pharmacy vendor are not covered under the Medicare Supplement Plan.
For certain prescription drugs:
You must call Express Scripts for pre-certification of certain prescription drugs. This applies whether you are inside or outside the United States.
In some cases, you may be required to try one or more specified drugs to treat a particular medical condition before the plan will cover another (usually more expensive) drug.
Additionally, as part of Express Scripts’ Advanced Utilization Management (AUM) program, certain targeted drugs will not be covered unless pre-certified by Express Scripts, based on medical evidence submitted by your physician.
Non-targeted drugs are covered without precertification or prior authorization. Refer to the Prescription drug program section for more details.
You must identify yourself as a member of the Express Scripts retail pharmacy program to receive Plan savings.
Call Express Scripts at 800-695-4116 or check the Express Scripts web site at www.express-scripts.com to locate a participating retail pharmacy near you.
A short-term prescription is written for a drug taken for a limited period of time, such as an antibiotic for a specific illness or if your doctor wants you to try the prescription before having a long-term prescription filled. The Plan provides benefits for up to a 34-day supply. See Covered prescriptions for limitations.
You have the choice of filling your prescriptions at:
- A local participating retail pharmacy (part of Express Script's extensive network of retail pharmacies), where you will pay your share — co-payment — of the discounted cost. There are no claims to file.
- A non-participating pharmacy of your choice, where you will pay the full retail price and file a claim for partial reimbursement of the cost.
To receive the discounted price:
- Present your prescription and either your prescription drug identification card or the primary participant's identification number at a participating network pharmacy.
- The pharmacist enters the prescription and the primary participant's identification number into the pharmacy's computer system to confirm:
- That you are a participant or family member covered by this option.
- That it is a covered prescription.
- Your share of the prescription's cost.
- You do not file a claim.
The term primary participant refers to the participant whose identification number is used for identification purposes. The primary participant is the retiree, survivor or individual who elected COBRA coverage. Covered family members use the primary participant's identification number to access all medical benefits. Be sure to give identification cards or the primary participant's identification number to your spouse and any covered family members who may live away from home.
Refills too soon?
Refills can be obtained if prescribed and needed. You must have used at least 75% of the previous prescription, based on the dosage prescribed, before you can obtain a refill and receive Plan benefits.
For prescription drugs purchased at a participating retail pharmacy, you pay a percentage of the discounted cost of the drugs.
Generic drug purchased at a retail network pharmacy — discounted cost of medication is $24.
You pay 30% co-payment ($24 x .30) = $7.20
Preferred brand name drug purchased at a retail network pharmacy (if no generic is available) — cost of medication is $42.
You pay 30% co-payment ($42 x .30) = $12.60
Non-preferred brand name drug purchased at a retail network pharmacy (if no generic is available) — cost of medication is $64.
You pay 50% co-payment ($64 x .50) = $32
Retail refill limitation
For the third and subsequent refills of a long-term or maintenance drug, which is a drug you take for an extended period of time, such as for ongoing treatment of diabetes, arthritis, a heart condition or high blood pressure, you will pay an additional 25% percentage co-payment. The additional 25% co-payment does not apply to your annual prescription drug out-of-pocket maximum.
For example, the percentage co-payment for a generic maintenance drug purchased at a retail network pharmacy is 55%.
Retail pharmacy percentage co-payment for the third and subsequent refill of a long-term maintenance drug:
- Generic drugs 55%
- Formulary preferred brand name drugs 55%
- Formulary non-preferred brand name drugs 75%
Using a non-participating pharmacy or not identifying yourself as a express scripts participant
You are not eligible for a discounted price if you:
- Have your prescription filled at a non-participating pharmacy; or
- Do not identify yourself as an Express Scripts participant at a network pharmacy.
In either case:
- You pay the full non-discounted price of the prescription at the time of purchase.
- You must submit a completed Direct Reimbursement Claim Form to Express Scripts. You may obtain a claim form by calling Express Scripts at the number shown in the front of this SPD.
- You will be responsible for:
- 100% of the difference between the non-discounted and discounted cost of the prescription (the ineligible cost);
- Your percentage co-payment portion of the discounted cost.
This example shows how you would save money when you use a network pharmacy and show your prescription ID card. In this case, you would save $10.
A long-term or maintenance drug is one you take for an extended period of time, such as for ongoing treatment of diabetes, arthritis, heart condition or high blood pressure. The Plan generally provides benefits for up to a 90-day supply through the mail-order prescription service. See Covered prescriptions for limitations.
If you need maintenance medication immediately, ask your doctor for two prescriptions — one for an immediate supply to be filled at a local pharmacy and a second for an extended supply to be ordered by mail.
Express scripts pharmacy — mail-order pharmacy
With Express Scripts Pharmacy, the mail-order pharmacy, you save money and have the convenience of home delivery. Ask the doctor to write a prescription for up to a 90-day supply with appropriate refills. Enclose your original prescription(s) and payment of your percentage co-payment in an envelope. If you are paying via check or money order, you may obtain a calculation of your percentage co-payment from the Express Scripts web site or by calling Express Scripts directly. If you are paying via credit card, Express Scripts will deduct the appropriate percentage co-payment and you will receive notification of the deduction with your medication.
For each prescription filled, you pay:
Your prescription will be delivered to the address on your order form within 14 working days. By law, prescriptions may not be sent outside the U.S.
You may order refills by calling Express Scripts or sending in the refill label provided with your previous order. You may also order refills through Express Scripts web site. You should order a refill about three weeks before your current supply will be exhausted, but remember that you must have used at least 75% of the previous prescription based on the prescribed dosage.
Comparing retail pharmacy with Express Scripts Pharmacy
This example shows how you can save money by purchasing long-term medication through the mail-order pharmacy.
Assume you purchase a 90-day supply of a preferred brand name drug:
By purchasing a 90-day supply of this prescription through mail order, you would save $16.20. That is $64.80 a year for one prescription. Note this example does not include in the calculation the additional 25% co-payment for the third and any subsequent refills from a participating retail pharmacy. Actual savings may be greater.
Whether you fill prescriptions through Express Scripts Pharmacy, at a local pharmacy or through Express Scripts Specialty Pharmacy:
- Your payments and co-payments under the outpatient prescription drug benefits do not apply toward your deductible for other benefits under the Plan.
- Your prescription drug payments and co-payments do not apply toward your annual medical out-of-pocket limit.
- Your prescription drug annual out-of-pocket maximum is $2,500 for each individual in your family, or $5,000 for your entire family. Additionally, there is a per prescription out-of-pocket maximum for drugs purchased at retail and through mail order, as shown in the table.
- The additional cost for purchasing brand-name prescription drugs when a generic is available, in addition to the additional coinsurance charged for purchasing third and subsequent refills of maintenance medications obtained at retail pharmacies, will not count toward your annual out-of-pocket maximum.
The Plan covers drugs, medicines and supplies that are:
- Obtainable only with a physician's prescription or are specifically covered expenses (see Covered expenses);
- Approved by the U.S. Food and Drug Administration for the specific diagnosis;
- Medically necessary;
- Not experimental or investigational.
- Prescription smoking deterrent medications.
- Outpatient prescription drugs unless you are enrolled in Medicare Part D.
The program encourages consideration of generic alternatives, which are less expensive to you and the Plan. About half of all brand name medications have a generic equivalent available. By law, the brand name and generic medications must meet the same standards for safety, purity, strength and effectiveness. The pharmacist will only dispense generics which receive FDA approval and only if authorized by your doctor.
Note: If both generic and brand name drugs are available to treat your condition, your percentage co-payment amount will depend on which medication you select. If you purchase the brand name drug, you are responsible for paying the generic drug percentage co-payment PLUS the difference in cost between the generic drug and the brand name drug up to the brand per prescription maximum. This difference in cost will not count toward your annual prescription drug out-of-pocket maximum.
Here is an example of how you can save by choosing a generic drug at a retail pharmacy when a brand-name drug is available on the Plan's formulary list of medications.
Sometimes, a generic drug or a less expensive brand name drug which provides the same therapeutic effect, but at a lower cost to you, may be available. If so, the network system will inform the pharmacist that a less expensive alternative medication is available to fill your prescription. A pharmacist from the network or Express Scripts Pharmacy may contact your doctor to discuss the generic or less expensive brand name alternative. If the doctor authorizes a substitution, the pharmacist will dispense it based solely on your doctor's agreement. If Express Scripts Pharmacy fills a prescription with a generic or an alternative brand name drug, your order will include an explanation of the doctor's change and a credit for any excess co-payment.
The network formulary program
A formulary is a list of commonly prescribed medications within particular therapeutic categories. The drugs on the list have been selected based on their effectiveness and cost. To be included in the formulary list, a drug must meet rigorous standards of approval by the Express Scripts Pharmacy and Therapeutic Committee - a group of nationally recognized medical professionals.
It is always up to your doctor to decide which medications to prescribe. If you have questions about the Express Scripts formulary, you should contact Express Scripts directly.
Drug monitoring service
All prescriptions, both mail order and retail, are screened by the network's computerized drug monitoring service.
This service analyzes all of your prescriptions in the system for potential problems such as adverse drug interactions, drug duplications and unusually high or low dosages. This service will also detect if a refill is requested too soon. If a potential problem is detected, the drug monitoring service transmits a message to the pharmacist. The pharmacist will contact your doctor about the potential problem or otherwise resolve the issue before dispensing the prescription. Of course, your doctor makes the final decision about any change in your prescription or course of treatment.
In most cases, the pharmacist will fill the prescription according to the doctor's written orders. However, there are some limitations:
- If the prescription is written for an amount that is greater than the Plan covers, the pharmacist will fill the prescription up to the Plan limit. You have the option to buy the additional amount at that time if purchasing at a retail pharmacy, but there is no Plan benefit.
- If the medicine is a controlled substance or if there is a manufacturer's or prescription benefit manager's directive, a smaller amount may be provided.
- You must use at least 75% of the prescription, based on the dosage prescribed, before you can obtain a refill and receive Plan benefits.
When a prescription drug becomes available over the counter
When a prescription medication becomes available over the counter, so that it can be purchased without a prescription, at the same strength and for the same use, it will no longer be covered under the Prescription Drug Program. In addition, other drugs in the same therapeutic class may be excluded from the program, but this determination will be made on a case by case basis, based on available clinical data.
Special rules for coordinating benefits for prescriptions
If you or your family members are covered under any other group medical plan, the Plan coordinates benefits with that plan, as described in the Coordination of benefits section of this SPD. In addition, information about the other coverage is provided to the outpatient prescription drug network.
When a pharmacist reviews your family member's eligibility information in the network system, a code will indicate if your family member has other coverage that should pay benefits first. In these cases, you must first pay according to the primary plan provisions (i.e., you cannot purchase prescriptions using the Express Scripts card or through the mail-order prescription service). After the primary plan has paid, you may file a claim with the Plan for reimbursement of any remaining amount; the procedure is the same as when a non-participating pharmacy is used. The Plan will pay the lesser of what would have been paid if the claim was not filed with the primary plan or the amount not paid by the primary plan.
Medicare Advantage (Part C) Plans, Medicare Part D, and The Prescription Drug Program
Participants who choose to enroll in a Medicare Advantage (Part C) plan which provides a Medicare prescription drug benefit or Medicare Part D Prescription Drug Plan will no longer be eligible for outpatient prescription drug coverage under the Plan. If you enroll in a Medicare Part C plan which provides a Medicare prescription drug benefit or Part D program and continue your Plan participation, your required contributions remain the same, but you will not be eligible for outpatient prescription drug benefits under the Plan.
Advanced utilization management program
In some cases, you may be required to try one or more specified drugs to treat a particular medical condition before the plan will cover another (usually more expensive) drug. Prior authorization and preferred drug step therapy rules are designed to encourage the use of effective, lower-cost drugs.
As part of Express Scripts’ Advanced Utilization Management (AUM) program, certain targeted drugs will not be covered unless pre-certified by Express Scripts, based on medical evidence submitted by your physician. In addition, some therapies will be monitored for appropriate pharmacogenomic parameters, and oral oncology medications will be limited to ensure appropriate use. Please visit www.express-scripts.com to more information about your medications and if they require a coverage review. If you have a question regarding a drug on the AUM program list, contact Express Scripts at the number listed in the Information Sources section of this SPD.
Pre-certification: preferred drug step therapy rules
You must call Express Scripts for pre-certification of certain prescription drugs described below:
Preferred drug step therapy rules are used for certain therapeutic chapters of drugs, to encourage the use of effective, lower-cost drugs by excluding some targeted medications from coverage. In the therapeutic chapters including: proton pump inhibitors, sleep agents, depression, osteoporosis, respiratory, cardiovascular, triptans, growth hormone, stimulants for Attention Deficit Hyperactivity Disorder, prostate therapy drugs, topical steroids, and stroke prevention, there will be targeted drugs determined by Express Scripts which will not be covered unless pre-certified by Express Scripts. Non-targeted drugs will be covered without such authorization and will continue to be dispensed with no further action by either you or the prescribing physician. If you have a question regarding a drug in any of these therapeutic chapters, contact Express Scripts to determine whether your drug is covered. You will be notified directly by Express Scripts if you are affected by these rules.
Prior authorization rules
New prior authorization rules apply to certain therapeutic chapters of drugs; some therapies in this section will be monitored for appropriate pharmacogenomics parameters. These classes include miscellaneous immunological agents, central nervous system/miscellaneous neurological therapy, biotechnology/adjunctive cancer therapy, central nervous system/headache therapy, central nervous system/analgesics, neurology/miscellaneous psychotherapeutic agents, and miscellaneous pulmonary agents. In addition, anabolic steroids, high cost antibiotics, anti-emetics, antivirals, narcotics, acne dermatologicals and topical pain medications may trigger a prior authorization. Oral oncology medications will also be limited to ensure appropriate use. Certain drugs within each chapter as determined by Express Scripts will only be covered to the extent they are authorized by Express Scripts. If you have a question regarding coverage for a drug in any of these therapeutic chapters, contact Express Scripts. You will be notified directly by Express Scripts if you are affected by these rules.
Express Scripts’ split fill program applies to certain select specialty conditions where participants often stop or change therapy early in treatment due to side effects or their ability to tolerate treatment. This program will provide smaller initial fills (15-day supply) and clinical support to participants as they begin their therapy. Coinsurance and the per prescription maximum will be applied on a prorated basis so that the participant will not be disadvantaged financially. This program is designed to help manage side-effects, eliminate wasted medications and manage specialty drug costs.