How prescription drug benefits work

​​Your medical coverage automatically includes prescription drug coverage through Express Scripts.* Express Scripts offers a network of participating retail pharmacies (including a mail-order service) and maintains a formulary of preferred prescription medications.

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.

*Those enrolled in Triple-S or GeoBlue should consult their plan for information about prescription drug benefits. Retired members covered by the Medicare Supplement Plan have access to similar prescription drug benefits through Express Scripts but do not receive reduced copays for preventive drugs.

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. 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 must get prior authorization from Highmark Blue Cross Blue Shield to fill a prescription for medical injectable drugs. To obtain such a prior authorization, call the number on the back of your medical identification card.

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.

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 copayment minimums and maximums as other prescriptions. Contact Accredo at 800-803-2523 for more information.

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.

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