Applies to HealthLink OAP, Coventry Health Care OAP and QCHP Only
Self-insured managed care plans (i.e., HealthLink OAP and Coventry Health Care OAP) and the Quality Care Health Plan (QCHP) have prescription benefits administered through the prescription benefit manager (PBM), Express Scripts. Prescription benefits are independent of other medical services and are not subject to the medical plan year deductible or out-of-pocket maximums.
Two important notes regarding this coverage are (1) over-the-counter drugs are not covered, even if purchased with a prescription, and (2) if a plan participant elects a brand name drug and a generic is available, the plan participant must pay the cost difference between the brand product and the generic product, in addition to the generic copayment.
Pharmacies that contract with Express Scripts and accept the copayment amount are referred to as network pharmacies. Plan participants should use a pharmacy network for prescriptions whenever possible to yield the most economical benefit.
- The maximum fill of nonmaintenance medication at a network retail pharmacy is a 60-day supply. If a plan participant uses a pharmacy in the Nonmaintenance Medication Network to fill a maintenance medication they will be charged double the copayment amount after the first two 30-day fills (or after the first 60-day fill). Therefore, plan participants should use a pharmacy in the Maintenance Network to fill prescriptions for maintenance medications.
- Plan participants can receive a 90-day supply of maintenance medication for two and a half times the copayment if they use the mail order pharmacy or a pharmacy in the Maintenance Medication Network.
Links to network lists and mail order forms are below:
In addition, participants should read the following regarding their pharmacy benefit:
- Participants who do not use one of these networks for their prescription needs and instead use an "out-of-network" pharmacy will, in most cases, have higher prescription drug costs since these pharmacies do not contract with Express Scripts.
- Out-of-network pharmacies are pharmacies that do not contract with Express Scripts. In most cases, prescription drug costs will be higher when an out-of-network pharmacy is used.
- If a medication is purchased at an out-of-network pharmacy, the plan participant must pay the full retail cost at the time the medication is dispensed. Reimbursement of eligible charges will be at the applicable brand or generic in-network price minus the appropriate in-network copayment.
- Reimbursement of eligible charges must be obtained by submitting a paper claim and the original prescription receipt to Express Scripts. See reimbursement process below.
Plan participants who either (1) did not have their eligibility verified at the time they purchased medication or (2) purchased their medication at an out-of-network pharmacy may file a request for reimbursement of eligible charges by filing a Express Scripts Claim Form.