Prescription Drugs
Prescription drug services are provided through Express Scripts, Inc. (ESI) and are included with each of the medical plans noted above. The Prescription co-pays are based on Drug Tier and Health Plan as shown in the table below.
| Drug Tier | PPO / EPO | HDHP |
|---|---|---|
| Retail Pharmacy- Generic (per 30-day supply) | $10.00 copay | $10.00 copay, after deductible |
| Retail Pharmacy - Preferred Brand (per 30-day supply) | $20.00 copay | $20.00 copay, after deductible |
| Retail Pharmacy- Non-Preferred Brand (per 30-day supply) | $35.00 copay | $35.00 copay, after deductible |
| Mail Order (up to 90-day supply) | Same as 1x retail copay | Same as 1x retail copay, after deductible |
The Authority subscribes to ESI’s Generic Preferred Program. If you have a prescription for a brand name drug and a chemically equivalent generic drug is available, the generic will be supplied. You will have the option of choosing either the generic equivalent or the brand name drug but if you choose the brand name drug, you will pay the brand name co-pay plus the difference in cost between the generic and the brand name drug.
The Authority also subscribes to ESI’s Advantage-Plus Utilization Management program which includes the following requirements for certain prescription drugs: Select Home Delivery – Incentive Choice, Quantity Management, Prior Authorization, and Step Therapy. Your pharmacist will advise you if your prescription is subject to one of these requirements.
- Under the Select Home Delivery – Incentive Choice (SHD-IC) option, The Authority is encouraging participants to utilize Mail-Order services to re-fill maintenance drug prescriptions rather than re-fill maintenance drugs at the Pharmacy. If you re-fill a maintenance drug at the Pharmacy, you will have to pay a copay for each 30-day supply. You will pay 1x the applicable copay for a 30-day supply; 2x copay for a 60-day supply; and 3x copay for a 90-day supply at the Pharmacy. Through Mail-Order you can fill 30, 60 or 90-day supplies and pay only 1x copay. Express Scripts will send letters to members who are affected. You will be allowed two (2) refills at the Pharmacy before the higher copay levels will apply. You can enroll for Home Delivery on the Express Scripts website.
- Drug Quantity Management (DQM) will limit how much medicine a member can obtain at one time for certain prescriptions (like opioids) while ensuring that the member receives the safest, most effective medicine available. This also helps lower overall drug costs by reducing the waste of unused medications.
- Under Prior Authorization (PA), certain prescriptions will require review by Express Scripts before the drug can be filled and covered by the Plan. Member’s doctor will need to provide Express Scripts with detailed information about the member’s drug treatment plan to ensure its use falls within the Plan rules. The purpose of this requirement is to make sure members get the safest, most effective medicine available at reasonable cost to you and the Plan.
- Under Step Therapy (ST), certain prescriptions will no longer be covered without a trial of preferred alternatives first and will cost the member more. Member’s doctor will need to provide Express Scripts with confirmation that preferred alternatives were tried and failed before the prescription will be filled and covered by the Plan. Preferred generics or lower-cost brand medicines work just as well for most people and typically cost a lot less. You can find a list of the National Preferred Formulary (NPF) alternatives on the Express Scripts website.
SPECIALTY PRESCRIPTION DRUGS
ACCREDO
The Authority utilizes a mandated specialty pharmacy service through ESI in partnership with Accredo, which will provide specialized support and service to employees and dependents taking specialty medications, including infusion therapies.
SAVEON SP
Through ESI in partnership with Saveon members taking specialty medications have access to manufacturer discount offers that may reduce your co-pay to $0.
Information will be mailed to your home containing details if you or your dependent qualify for the specialty pharmacy service or a manufacturers’ discount.