Explanations of prescription benefit
Prescription drugs through Express Scripts
Go to www.express-scripts.com and follow the steps to register. Then log on to price medications, view the Express Scripts’formulary list (preferred drugs), locate a participating pharmacy, etc.
All prescription drug benefits plans are provided through Express Scripts. You may fill prescriptions:
- By mail order (This is required for maintenance medications.)
- At one of 55,000 participating retail pharmacies nationwide (You must present your ID card.)
- At any nonparticipating retail pharmacy
You receive the highest possible benefit when you purchase medications through the mail order pharmacy.
However, if you wish, you may purchase a total of three fills of a maintenance medication at a retail pharmacy (one original fill and two refills). Additional fills of the same medication at a retail pharmacy will not be covered.
It is up to you and your doctors to decide which prescription drugs are best for you. You are never required to use either generic drugs or drugs that are on the preferred, formulary list. However, if you purchase a brand name medication when a generic equivalent is available, the plan will cover only up to the cost of the generic drug.
Visit Express Scripts to price a medication. Download the formulary in the table above and share it with providers who prescribe your medication. Encourage your provider to prescribe a Tier 1 or Tier 2 drug if possible.
High Deductible Health Plan benefits
Use your Express Scripts ID card to purchase prescriptions and take advantage of Express Scripts discounts. Once you reach your combined deductible for medical and prescription drug costs, the plan pays a percentage of prescription costs.
Retail deductible – Participants have been asked to pay the first $50 of the retail pharmacy drug cost before the plan kicks in.
For example, if your first 2013 prescription is for a formulary name-brand antibiotic whose retail cost is $145.
You will pay the first $50 of the cost as your deductible
You will also pay the formulary name-brand copay of $35.
The prescription plan will cover the remaining $60.
After you meet the deductible, you pay only the appropriate copay.
Generic or pay the difference -This means that if you want the name-brand version of a drug that is available in generic form, you will be required to pay the generic copay plus the difference in the retail cost of the two medications.
For example, there is a formulary name-brand drug that costs $69.
The drug has a generic equivalent that costs $30.
If you want the name brand, you will pay the $10 generic copay.
You will also pay the $39 difference in the cost of the two products.
Mandatory mail order -You are required to obtain maintenance medications from the mail-order service; after the first three months there will be no coverage for the prescription if you try to fill it at a retail pharmacy.
If, for example, you begin to take a prescription for cholesterol on March 15, 2013, you will get the original prescription at the pharmacy. After you get the second fill (that is, the first refill) of the prescription, Express Scripts will be in touch with you to remind you that after your third fill (second refill) you will need to mail away for a three-month supply if you need to continue the medication. There will be no exceptions. If you go to the pharmacy on June 15 for a fourth fill (third refill), you will have to pay the full cost of the medication.
After your first three months on the medication (original fill plus two refills), prescription coverage will be available only through the mail-order home delivery system.
Annual Prescription Deductible for mail order
Exceptions to the mandatory mail-order – In some circumstances, you may not be required to use the mail-order pharmacy. For example, there are several categories of medications that are uniquely appropriate for multiple refills at your local pharmacy [and are therefore exempt from the mandatory mail-order provision as outlined above]. If you have a prescription for some anti-infectives, antifungals, acute pain medications[not NSAIDs] and others you may be able to receive multiple refills at your retail pharmacy. See the Prescription Drug Benefits summary for more details.
Non-Sedating Antihistamines -The drug category of non-sedating antihistamines (examples: Clarinex, Allegra, Zyrtec) has been moved to the highest copay, even if the medication is on the formulary. This change is a result of the drug Claritin now being available over the counter. For example, if you prefer to take the medication Clarinex, rather than buying Claritin over the counter, you will pay the third tier copay of $60 at retail or $150 for a three-month supply at home delivery.
However due to changes in the IRS guidelines covering Flexible Spending Accounts [FSA] you can now claim this as a reimburseable expense on your FSA.
Diocesan Benefits Coordinator