Prescription drug benefits are included as part of the State Health Plan. Prescription drugs are a major benefit to you and a major part of the cost of our self-insured health plan. Using generic drugs saves you and the plan money. You also can save money and receive the same FDA-approved drugs when you refill prescriptions through the plan’s Retail Maintenance Network or mail-order prescription service. Benefits are paid only for prescriptions filled at network pharmacies or through Express Scripts mail-order pharmacy, in the United States. Limited coverage is offered outside the United States.
Using your prescription benefits
You will receive one pharmacy benefits card from Express Scripts, the State Health Plan pharmacy benefits manager. Simply present your card when you fill a prescription, particularly the first time you use your card, and any time you fill a prescription at a different pharmacy.
Standard Plan members pay a copayment when filling prescriptions at a network pharmacy. Copayments are $9 for Tier 1 (generic – lowest cost), $38 for Tier 2 (brand – higher cost) or $63 for Tier 3 (brand – highest cost) for up to a 31-day supply. The prescription drug copayment is a fixed total amount a member must pay for a covered drug. The prescription drug benefit has a separate annual copayment maximum of $2,500 per
person. This means that after you spend $2,500 in prescription drug copayments, the plan will pay 100 percent of the allowed amount for your covered prescription drugs for the rest of the year.
Savings Plan members do not pay a copayment when filling prescriptions at a network pharmacy. You pay the full allowed amount for your prescription drugs, and a record of your payment is transmitted electronically to BlueCross BlueShield of South Carolina. If you have not met your annual deductible, the full allowed amount for the drug will be credited to it. If you have met your annual deductible, you will pay 20 percent of the allowed amount for the drug. This amount will be credited to your coinsurance maximum.
Express Scripts Medicare®
If you are enrolled in the State Health Plan as an active employee, there are no changes in your prescription drug coverage when you or your covered dependents become eligible for Medicare. PEBA automatically enrolls Medicare-eligible retirees and their Medicare-eligible dependents in Express Scripts Medicare®, the State Health Plan’s Medicare Part D program. However, you have the option to return to the SHP Prescription Drug Program, which covers members who are not eligible for Medicare. For information about Express Scripts Medicare®, see the When You Become Eligible for Medicare handbook.
Physicians and pharmacists continually review and compare the medications on a pharmacy network’s formulary, which is the network’s list of preferred drugs, including new drugs and generics. As a result, some safe and effective drugs become “preferred” and others may become “non-preferred.”
What are “preferred” and “non-preferred” medications?
Preferred, or formulary, medications are effective medications that are similar to non-preferred medications. This list of drugs is determined based on the advice of pharmacists and a group of independent doctors. Preferred medications cost less than non-preferred medications.
Please note: Not all drugs on the list are covered by all prescription plans and the formulary list might not show every covered drug.
Non-preferred, or non-formulary, medications are those medications not on the State Health Plan’s list of recommended drugs and therefore may cost you more.
If you currently are prescribed a drug that is not on the preferred list, we encourage you to talk with your doctor about prescribing preferred drugs that are on the formulary list. Doing this can save you money, and using generic drugs may save you even more.
You must use a participating pharmacy and show your health plan identification card when purchasing medications. Most major pharmacy chains and independent pharmacies participate in the network. A list of network pharmacies is available by logging in to your Express Scripts account.
Some medications will be covered by the plan only if they are prescribed for certain uses. These drugs must be authorized in advance, or they will not be covered under the plan. If the prescribed medication requires prior authorization, you, your doctor or your pharmacist may begin the review process by contacting Express Scripts at 855.612.3128.
Order a replacement ID card
You may order replacement prescription drug ID cards by calling Express Scripts at 855.612.3128, by visiting the Express Scripts website at www.Express-Scripts.com or by downloading the Express Scripts app on your mobile device. You will need your Benefits Identification Number (BIN). If you don’t know your BIN, login to MyBenefits and select “Get My BIN.”