How prescription drug benefits work

Key features of your prescription drug benefits include the following:

• You can save on your out-of-pocket costs for covered drugs by selecting generic or formulary brand drugs and using the mail-order service when appropriate.
• You can maximize your savings when you use drugs that are on the preventive drug list. These are select preventive prescription drugs that are highly effective in preventing or managing chronic conditions, such as diabetes, high blood pressure, and osteoporosis.
• PPO and EPO members pay reduced copays for these drugs.
• HDHP members pay only a flat-dollar copay with no deductible for these drugs.

*Retired members with medical coverage through the Board of Pensions and those enrolled in Triple-S or GeoBlue should consult their plan for information about prescription drug benefits.

Special programs

Some prescribed drugs are subject to step therapy, prior authorization, quantity limits, or specialty medication programs — additional ways the prescription drug program seeks to slow rising costs while providing you with safe and effective medications.

Step therapy

In some cases, you will need to first try certain cost-effective drugs (usually generics) to treat your medical condition before the plan will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, the plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, the plan will then cover Drug B.

To find out if step therapy applies for your medication, log on to the Express Scripts website and use the Price a Medication tool. Or, call Express Scripts at 800-344-3896. You may also call Quantum Health at 855-497-1237 for personalized assistance.

Note: The step therapy list is subject to change.

Prior authorization

A prior authorization requires you or your physician to get approval from Express Scripts before you fill prescriptions for certain drugs. If you do not get approval, the drug may not be covered.

Drugs that require prior authorization typically are drugs that are very costly or have significant potential for negative side effects. When you present a prescription for one of these drugs — growth hormones, for instance — the pharmacy receives notice that certain clinical information must be obtained from your physician before it can fill the prescription. You can find out if a drug requires prior authorization by using the Price a Medication tool on the Express Scripts website or by calling Express Scripts at 800-344-3896. You may also call Quantum Health at 855-497-1237 for personalized assistance.

You must get prior authorization from Quantum Health to fill a prescription for medical injectable drugs. To obtain such a prior authorization, call Quantum Health at 855-497-1237.

Quantity limits

For certain drugs, there is a limit on the amount of the drug that will be covered. To find out if quantity limits apply for your medication, log on to the Express Scripts website and use the Price a Medication tool. Or, call Express Scripts at 800-344-3896. You may also call Quantum Health at 855-497-1237 for personalized assistance.

Specialty medications

Specialty medications, typically used to treat complex conditions such as cancer, hepatitis, and multiple sclerosis, are limited to a 30-day supply due to high costs, special storage needs, limited shelf life, and frequent dosage changes.

Specialty drugs must be purchased through Accredo, an Express Scripts specialty pharmacy, to be covered under the prescription drug program; specialty medications are not available through Express Scripts Pharmacy home delivery service or your local retail pharmacy.

Specialty medications are subject to the same deductible requirements (HDHP only) and coninsurance minimums and maximums as other prescriptions. Contact Accredo at 800-803-2523 for more information.

SaveOnSP

If you are enrolled in the PPO or EPO, you may be eligible to participate in a copay assistance program designed to save you money on certain specialty drugs. The copay assistance program, administered by SaveOnSP, supports you with enrollment in the drug manufacturer’s copay assistance program so you can pay as little as $0 out of pocket. If you do not enroll in the program when eligible, you will be responsible for the usual coinsurance for your drug with no maximum amount, and your coinsurance will not count toward your prescription out-of-pocket maximum (PPO only) or total maximum out-of-pocket amount. For more information about SaveOnSP, contact Quantum Health at 855-497-1237.

Note: The SaveOnSP program is not available if you are enrolled in the HDHP.

Excluded drugs

The Board of Pensions and Express Scripts are attempting to slow the rise in drug costs by excluding certain medications from coverage when less expensive, clinically proven alternatives are available on the formulary.

• Always check the drug formulary and exclusion list before filling a new prescription; the list is updated twice a year.
• If you fill a prescription for a drug that is excluded from coverage, you'll pay the full (unreduced) cost of the drug, and that payment will not count toward your total out-of-pocket maximum. If you’re enrolled in the PPO, it also will not count toward your prescription out-of-pocket maximum.

In addition, the EPO and HDHP do not cover non-formulary drugs.