How the Prescription Drug Plan Works

Express Scripts, Inc. (ESI) administers the benefits and offers a broad choice of covered drugs through a nationwide pharmacy network. Subscribers will receive a separate prescription ID card upon enrollment. Contact ESI for more information.

1. The member receives a prescription from a health care provider.
2. Fill the prescription. Depending on the medication, members have several options in which to fill their prescriptions:
1. Short-term medications can be filled at a retail pharmacy.
2. Members taking ongoing, maintenance medications may decide whether they would like to fill it at a retail pharmacy or through ESI’s Home Delivery (see Home Delivery and Retail Pharmacy for more information).
3. Specialty Medications must be filled through Accredo, ESI’s home delivery pharmacy provider.
3. Pay for prescription. Drug costs are based on the drug tier (generic or preferred* brand, or non-preferred) and where the prescription was filled (retail pharmacy or home delivery). PPO Plan members pay a copayment. HSA Plan members pay the full discounted cost of the prescription until deductible is met. After that, HSA members pay coinsurance (see Benefit Chart for more information).
1. Some prescriptions are covered at 100%. See Preventive Services for more information.
4. Members will continue to pay prescription copayments/coinsurance until their out-of-pocket maximum is reached. At that time, the plan will begin to pay 100% of covered expenses. For PPO Plans, the prescription and medical out-of-pocket maximums are separate. For the HSA Plan, the prescription and medical out-of-pocket maximum is combined.

Additional Plan Information

Reserved Rights — MCHCP reserves the right to pay only for those medications prescribed by a physician, filled at an assigned pharmacy, and approved by MCHCP if drug misuse, abuse or fraud is suspected.

Preauthorization — ESI requires preauthorization for specific medications. This means proof of medical necessity is required before a prescription for certain drugs is paid for by the plan. The purpose is to prevent misuse and off-label use of expensive and potentially dangerous drugs. If preauthorization is required, member’s physician should call ESI's Preauthorization line at 800-417-8164. These drugs are noted with “PA” next to them in the formulary.

Step Therapy — In some cases, members are required to first try certain drugs to treat their medical condition before Express Scripts, Inc. (ESI) will cover another drug for that condition. For example, if Drug A and Drug B both treat the medical condition, ESI may not cover Drug B unless you try Drug A first. If Drug A does not work for you, ESI will then cover Drug B. These drugs are noted with “ST” next to them in the formulary. (See Step Therapy for more information.)

Quantity Level Limits — Quantities of some medications may be limited based on recommendations by the Food and Drug Administration (FDA) and medical literature. Limits are in place to ensure safe and effective drug use and to guard against stockpiling of medicines. These drugs are noted with “QLL” next to them in the formulary.

Compound Prescription Drugs — Members filling compounded medication prescriptions will receive notification from ESI if their prescription is not covered. The notification lists ingredients in the specific compounded medication(s) which are not covered because they are not approved by the FDA. MCHCP does not cover investigational, experimental or non-FDA approved products; therefore, ESI cannot process and pay claims for certain compound prescription drugs.