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 Express Scripts 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 Express Scripts Exclusive Home Delivery service or from a retail pharmacy.

Here’s a Snapshot of Your Prescription Drug Benefits:

Express Script 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 the Express Scripts Exclusive Home Delivery Service 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.

Smart90® Feature:  You can also get a 90-day supply at any Walgreens, Duane Reade or Happy Harry’s retail pharmacy, called the Smart90® feature.

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 Home Delivery or the Smart90® Feature. Send the second, 90-day prescription to the Express Scripts Exclusive Home Delivery service or take it to any Smart90® retail pharmacy.

The first time you use the home delivery service, go to express-scripts.com and download the mail order form or call Express Scripts at 1-866-577-2523. Send the completed form with your prescription to the address provided on the form.

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Prescription Drug Cost-Estimator (BCBSTX plans)

The prescription drug cost estimator tool 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 tool to learn more about opportunities for savings.

Medication Management

Express Scripts 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 Exclusive Home Delivery service or at any Walgreens, Duane Reade or Happy Harry's 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 Express Scripts 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, you doctor must contact Express Scripts 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 Express Scripts.

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 Express Scripts — 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, Express Scripts 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, Express Scripts 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 Express Scripts anytime to request pre-authorization and approval.

No Copay for Specialty Drugs

SaveonSP, a program through Express-Scripts, covers specialty drugs 100% (no copay or cost).

Enrollment in the program is voluntary. If you choose not to participate, you will be responsible for the copay. Keep in mind that the copay will not count towards your deductible or out-of-pocket maximum.

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

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 Express Scripts’ decision. Detailed information about how to submit an appeal will be included in the benefit denial letter you receive from Express Scripts or you can call Express Scripts at 1-866-577-2523.

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 Express Scripts Preferred Drug List for more information. If you enroll in the BCBSTX PPO, the diabetic insulin copayment will be $20 when obtained at a retail pharmacy and $50 for mail order or Walgreens retail pharmacy (90-day supply). The copayments for diabetic supplies under the BCBSTX PPO and BCBSTX HSA plans are $10 for retail pharmacy and $25 for mail order or Walgreens retail pharmacy.
• 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.