Prescription drug coverage is a benefit that allows you and your eligible dependents to obtain covered prescription drugs at negotiated prices. What you pay for prescriptions depends on:

• The medical plan you choose (Visit the Prime Therapeutics website for details)
• Whether you purchase more costly brand name medications or less costly generic equivalents
• Whether you buy your long-term maintenance medication from the home delivery service (administered by Express Scripts Pharmacy Mail Order) or from a retail pharmacy.

Here’s a Snapshot of Your Prescription Drug Benefits:

Prime Therapeutics administers the Prescription Drug benefit for all employees enrolled in the BCBSTX HSA or PPO Plans. You have three options for filling prescriptions.

Short-term medications (30-day supply): Fill at a network retail pharmacy for an immediate need, such as an antibiotic to treat an infection.    

You can fill a 30-day supply of maintenance medication through retail network pharmacies up to three times. Beginning with the fourth fill, you’ll be charged the entire cost of the drug if you continue to fill at a retail pharmacy.

Long-term medication (90-day supply): Fill through Express Scripts Pharmacy Mail Order for maintenance medication you take regularly for an ongoing health condition such as asthma, heartburn, or high cholesterol. You can fill up to a 90-day supply of maintenance medication, plus three 90-day refills, through this service.

90 Day My Way:  You can also get a 90-day supply at any Walgreens retail pharmacy.

When first prescribed a maintenance medication, ask your physician to write two prescriptions: one prescription for a 30-day supply to fill at a local retail pharmacy and a second for a 90-day supply plus three 90-day supply refills to fill through Express Scripts Pharmacy Mail Order or 90 Day My Way plan. Send the second, 90-day prescription to Express Scripts Pharmacy Mail Order or take it to any Walgreens retail pharmacy.

The first time you use the home delivery service, go to express-scripts.com/rx or call Express Scripts at 1-833-715-0942.

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Prescription Drug Cost-Estimator (BCBSTX plans)

The MyBlueRXTX app is a personalized pharmacy app for Blue Cross and Blue Shield of Texas (BCBSTX) members that helps you estimate your prescription drug costs before you purchase your medications. You can compare prices on generic and brand-name drugs, as well as other drugs in the same class. Use this app to learn more about opportunities for savings and to manage prescription drug care for your family.

Prescription Discounts

MedsYourWay is a prescription drug discount program that works with your BCBSTX pharmacy benefit. MedsYourWay automatically compares prices from participating drug discount cards to your cost-share amount under your pharmacy benefits and you pay the lower amount on eligible medications. Plus, what you pay will count toward your plan deductible and/or yearly out-of-pocket maximum.

Medication Management

Prime Therapeutics works with BMC to help you get the right kind of prescription medicine for your health, and to help you save money through medication management programs.

Generic Preferred

If you obtain a brand-name drug (preferred or non-preferred) when an equivalent generic drug is available, you will pay the brand name copayment (or coinsurance) plus 100% of the difference in cost even if your cost exceeds the maximum copayment per prescription (PPO Plan). This additional cost applies regardless of whether your doctor prescribes a brand-name drug.

Exclusive Home Delivery

You are required to fill all prescriptions you use on a regular basis, or for 90 days or more, through the Express Scripts Pharmacy Mail Order service or at any Walgreens retail pharmacy. If you choose to continue using the retail pharmacy for these medications beyond the first three fills, you will pay 100% of the cost of the medication.

Prior Authorization

Some medications require prior authorization from Prime Therapeutics before you can buy them. A prescription may not be approved if it does not meet certain criteria. If it is not approved, you must pay the full cost of the prescription. To get prior authorization, your doctor must contact Prime Therapeutics before the prescription is filled. Your doctor must provide the diagnosis, specific drug number, dosage and approximate treatment duration. If approved, your doctor will receive notification from Prime Therapeutics.

Smart Prior Authorization

Smart Prior Authorization automatically applies a set of rules for certain prescription drugs to determine if the medication, dose and quantity are appropriate for the patient’s condition. By applying factors that are on file with Prime Therapeutics — such as the member’s medical history, drug history, age or sex — the drug can often be dispensed without further evaluation.

Step Therapy

If you take medication to treat certain conditions, Prime Therapeutics works with you and your doctor to see if you should first try a less expensive brand or over-the-counter drug before trying the brand-name-only medication (a process called “step therapy”). As part of the step therapy program, a message is automatically sent to the dispensing pharmacist to encourage him or her to check whether a generic or preferred brand medication would be appropriate for you or your covered dependents. If you attempt to fill a prescription for a higher-cost non-preferred medication without having first tried the preferred medication, your prescription will not be covered. (Note: You can still fill your prescription but you will be responsible for paying the full cost.) If this happens, your pharmacist can contact your doctor to ask if you can switch to a generic alternative, or you can speak to your doctor on your own.

Quantity Management

Quantity Management means that for certain prescription drugs, Prime Therapeutics will limit the amount you receive at one time based on the manufacturer’s recommended dosages. It can also save you money by ensuring you receive the most cost-effective strength. If your doctor wants you to take more than the recommended amount, he or she can contact Prime Therapeutics anytime to request pre-authorization and approval.

Cost Assistance for Specialty Drugs

FlexAccess is a cost assistance program for BCBSTX PPO Plan participants designed to help you lower your costs if you take certain high-cost medications. Enrollment in the program is voluntary. If you choose not to participate, you will be responsible for the full cost of medication.

BCBSTX HSA Plan participants are eligible for the FlexAccess Qualified program to help lower out-of-pocket costs through drug manufacturer's coupons and copay assistance programs.

If you are taking a specialty drug on the impacted list, you will receive communication from FlexAccess to enroll in the right program for you.

If Your Claim is Denied

If you or a covered dependent receive a denial for a pharmacy benefit, you are entitled to a review of Prime Therapeutics’ decision. Detailed information about how to submit an appeal will be included in the benefit denial letter you receive from Prime Therapeutics or you can call Prime Therapeutics at 1-877-278-4420.

For more information, see Frequently Asked Questions about Medication Management.

• Certain prescription smoking cessation and weight reduction medications will be covered under the BCBSTX HSA and BCBSTX PPO Plans. Refer to the Prime Therapeutics Preferred Drug List for more information.
• Generic and single source preferred brand contraceptives are covered at 100% under all medical plans.
• The BCBSTX HSA Plan covers certain preventive prescription drugs — like insulin and blood pressure medicine —at 85% before the plan deductible. You pay 15% coinsurance for these medicines—even if you haven’t satisfied the annual plan deductible. However, the coinsurance you pay for preventive prescription drugs does not count toward meeting the BCBSTX HSA annual deductible or out-of-pocket maximum.
• Prescription drug expenses under the BCBSTX HSA and PPO plans will count toward satisfying your annual out-of-pocket maximum.
• If you enroll in the Kaiser HMO, prescriptions will be covered through Kaiser pharmacies only.