Prescription Drug Coverage

How Your Prescription Drug Coverage Works

For many people, taking medication to treat disease and improve health is an important part of maintaining health and managing disease. For most Trust members, prescription drug coverage is provided by Express Scripts (866-662-0274). The Plan provides coverage through a nationwide network of retail pharmacies, as well as a convenient mail-order program.

Medications are assigned to one of three copay categories known as tiers. When you fill a prescription, the copay amount for each prescription order or refill will be based on whether the drug is generic or brand name, the applicable “tier” of the drug and how the drug is dispensed (retail pharmacy or mail order). If the cost of the drug is less than your copay, you will only pay the cost of the drug. Copay amounts are established annually and announced in Benefit Highlights.

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2017 Copays for All Plans chart

Prescription Drug Copays

Medications are assigned to one of three copay categories called tiers. When you fill a prescription, the copay amount for each prescription order or refill will be based on:
 

1. Whether the drug is generic or brand name
The applicable “tier” of the drug

2. How the drug is dispensed (retail pharmacy or mail order)

3. If the cost of the drug is less than your copay, you will only pay the cost of the drug. Copay amounts are established annually and announced in Benefit Highlights.

 
Payment methods for mail-order prescriptions include check, e-check, money order and credit card. Extended payment options are available. We encourage you to join the Express Scripts automatic payment program to allow for credit card payments and uninterrupted service.

Generic/Brand Name & Retail Pharmacy/Mail-Order Delivery

 

 

Medication Type: Generic or Brand Name?

Generic drugs are nothing new and are widely available and carefully regulated. They offer all the same benefits as their brand-name counterpart at a fraction of the cost.

On average, the cost of a generic drug is 80 to 85 percent lower than the brand-name product.

For the greatest cost-savings to you and the Trust, request that your doctor prescribe a generic drug. In most cases, unless your doctor has indicated “Dispense As Written” or DAW, your prescription will be filled with the generic equivalent.

 
 

Filling Prescriptions: Retail Pharmacy or Mail-Order?

Filling prescriptions at an in-network retail pharmacy is appropriate for short-term needs - you can receive up to a 30-day supply at the retail copay (for example, filling a prescription for an antibiotic). Retail pharmacies are also appropriate for situations in which your physician has not established the suitable drug, strength and dosage for ongoing needs. To locate participating network pharmacies near you, contact Express Scripts by phone or use the online pharmacy look-up tool.

The mail-order option is an easier, more convenient and cost-effective way to get your ongoing prescription medications. By using mail-order, prescriptions are delivered right to your home – plus shipping is free. In most cases, you can order up to 90-days of prescription drugs at once. Using mail-order offers a great savings opportunity, since at most you pay twice the retail copay for three times the amount of medication.

Note: Non-Medicare members must use mail-order for maintenance medications (medications used for an ongoing basis to treat conditions such as high blood pressure or high cholesterol).

To submit your prescriptions for mail-order through Express Scripts, use the forms below:

NON-Medicare  Medicare

Coordination of Benefits/Direct Claim Form

When the pharmacy does not file the claim for you, the charges should be submitted directly to Express Scripts. Use the form below to seek reimbursement if you fill a prescription out of network. Please note, reduced reimbursement applies to prescriptions filled out-of-network.


Non-Medicare

If you are notified that a claim was denied, in whole or in part, you have two levels of appeal for prescription drug claims:

  1. To initiate a level 1 review, you must send Express Scripts a written statement explaining why you disagree with its determination. You need to include all documentation, records or comments you believe support your position.

  2. If you disagree with the response to the level 1 review, you will receive information in writing on how to initiate a level 2 review.

Medicare

If your prescription is denied at the pharmacy, your first step is to contact Express Scripts Medicare at 866-662-0274. This request will result in an initial determination. You or your prescribing doctor can ask for an initial determination by phone, unless you are seeking repayment for a drug that you already bought, in which case the request must be in writing.

If your initial determination is denied, you can request a redetermination, which must be in writing. You will receive instructions on applying for a redetermination with your initial determination.

Complete details on filing a claim or appeal can be found in the Summary Plan Description (SPD).

Prescription Drug Claims & Appeals

Always present your Express Scripts card when at the pharmacy to ensure the correct information is submitted for your claim. If a claim is denied in whole or in part, you have the right to file an appeal.

Claim Filing Deadline

Claims are due within 12 months of the date of service. Claims received after this period will be denied unless you can show it was not possible to provide such notice of claim within the required time and the claim was filed as soon as reasonably possible. 

Notice of Claim Decision/Appeals 

Express Scripts will provide you notice of the claim decision. The notice will be in writing and will inform you of the specific reasons for the decision. It will refer to the specific provisions of the plan on which the denial is based and explain whether any additional information is required from you. Express Scripts will decide your claim within the deadline for the type of claim involved (e.g. urgent claim, prior authorization).

To initiate a review or appeal of a decision, please call or write Express Scripts at:
Express Scripts
Attn: Coverage Reviews
8111 Royal Ridge Pkwy
Irving, TX 75063
800-753-2851

For medical plan claims and appeals, visit the Medical Benefits & Plan Types page.