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:
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.
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.
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.
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.
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.
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 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.
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 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.
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 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.
The Departments of the Treasury, Labor, and Health and Human Services (the Departments) have issued the Transparency in Coverage final rules (85 FR 72158) on November 12, 2020. The final rules require non-grandfathered group health plans and health insurance issuers in the individual and group markets (plans and issuers) to disclose certain pricing information. Under the final rules a plan or issuer must disclose in-network negotiated rates and billed and out-of-network allowed through machine-readable files posted on an internet website. Plans and issuers are required to make these files public for plan policy years beginning in 2022. This material is for information only. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. You can access the BMC machine readable files here.