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8
Prescription Drugs – Express Scripts
Prescription drug coverage provides a benefit that is important to your overall health, whether you need a
prescription for a short-term health issue like bronchitis or an ongoing condition like high blood pressure.
If you enroll in medical coverage, you will automatically receive coverage for prescription drugs.
Traditional PPO - Actives
High Deductible Health Plan (HDHP)
In-Network
Out-Of-Network
In-Network
Out-Of-Network
Prescription
Drug
Deductible
$0
$0
Combined with HDHP Medical Deductible
Annual Out-of-
Pocket Limit
Individual
Family
$4,985
$9,740
Combined with HDHP Medical Annual
Out-of-Pocket Limits
Pharmacy
Generic
$10 copay then plan
pays 100% (Mandatory
Generic when available)
$10 (non-ESI
pharmacy needs to pay
in full and submit for
reimbursement) copay
then plan pays 100%
Plan pays 80%
after deductible
Plan pays 80% after
deductible
Preferred
Brand
$30 copay then plan
pays 100%
$30 copay then plan
pays 100%
Plan pays 80%
after deductible
Plan pays 80% after
deductible
Non-preferred
Brand
$60 copay then plan
pays 100%
$60 copay then plan
pays 100%
Plan pays 80%
after deductible
Plan pays 80% after
deductible
Supply Limit
30 days
30 days
30 days
30 days
Mail Order
Generic
$20 copay then plan
pays 100%
Not covered
Plan pays 80%
after deductible
Plan pays 80% after
deductible
Preferred Brand
$60 copay then plan
pays 100%
Not covered
Plan pays 80%
after deductible
Plan pays 80% after
deductible
Non-preferred
Brand
$120 copay then plan
pays 100%
Not covered
Plan pays 80%
after deductible
Plan pays 80% after
deductible
Specialty Drug
20% up to $150
maximum
20% up to $150
maximum
N/A
N/A
Supply Limit
90 days
90 days
90 days
90 days
Mandatory Mail Order Starting January 1, 2018 For Traditional PPO
Members
After three (3) 30-day supply fills of any medication, succeeding refills
must be obtained through Express Scripts’ mail order service. Otherwise,
you will pay the full cost of the prescription if you choose to continue
having your prescriptions filled at retail pharmacies.