Applies to HealthLink OAP, Coventry Health Care OAP and TCHP Only
Self-insured managed care plans (i.e., HealthLink OAP and Coventry Health Care OAP) and the Teachers' Choice
Health Plan (TCHP) 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 out-of-pocket maximum.
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 at a retail pharmacy is a
60-day supply; however, plan participants can receive a 90-day supply
for two copayments if they use the mail order pharmacy (links to network
lists and 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
- 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.