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Public Entity Members

Prescription Drug Plan

Non-Medicare members automatically receive prescription coverage with MCHCP medical plan enrollment. 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.

Prescription Drug Formulary

A drug formulary is a list of FDA-approved generic and brand-name prescription drugs and supplies covered by your health insurance plan. ESI places covered drugs into three levels:  preferred generic, preferred brand or non-preferred.

Preferred drugs are covered at a lower cost to you. Non-preferred drugs are covered, but you will pay more than if you choose preferred brand or preferred generic drugs. If your health care provider prescribes a non-preferred drug, discuss preferred alternative options with your provider.

There are some drugs that are not covered. These drugs have a covered alternative option that can be discussed with your provider. In most cases, if you fill a prescription for one of these drugs, you will pay the full retail price. Your provider may request a clinical exception to cover the drug by calling Express Scripts’ Prior Authorization Line. Approved exceptions are covered as a non-preferred drug.

There are certain medications that MCHCP will cover at 100 percent1, when accompanied by a prescription and filled at a network pharmacy. See Preventive Services for more information.

ESI’s preferred formulary list is available here (2017 Formulary | 2018 Formulary | 2018 Exclusions) or by contacting ESI, and can change throughout the year. If you have a question about a drug you take, please call ESI at 800-797-5754.

  1. Drugs covered at 100 percent are those described in the United States Preventive Services Task Force A and B recommendations, the Advisory Committee on Immunization Practices (ACIP) of the CDC, and HRSA Guidelines for women, as well as children, including the American Academy of Pediatrics Bright Futures periodicity guidelines.

Benefit Chart

Member pays the cost of the drug or the copayment, whichever is less.

If a member requests a brand-name drug when a generic is available, the member pays the generic copayment plus the difference in the cost of the drugs.

There are certain medications that MCHCP covers at 100 percent, when accompanied by a prescription and filled at a network pharmacy. For more information, see Preventive Services.

Note: 32- to 60-day and 61-90-day supplies may not be available at all retail locations.

Description HSA Plan PPO Plans
Retail — Network (Up to 31-day supply) Retail — Network
(Up to 31-day supply)
Generic
Preferred
Non-Preferred
HSA Plan*
Generic — 10% coinsurance*
Preferred — 20% coinsurance*
Non-Preferred — 40% coinsurance*
PPO Plans
Generic — $8
Preferred — $35
Non-Preferred — $100
Retail — Network (32- to 60-day supply) Retail — Network
(32- to 60-day supply)
Generic
Preferred
Non-Preferred
HSA Plan*
Generic — 10% coinsurance*
Preferred — 20% coinsurance*
Non-Preferred — 40% coinsurance*
PPO Plans
Generic — $16
Preferred — $70
Non-Preferred — $200
Retail — Network (61- to 90-day supply) Retail — Network
(61- to 90-day supply)
Generic
Preferred
Non-Preferred
HSA Plan*
Generic — 10% coinsurance*
Preferred — 20% coinsurance*
Non-Preferred — 40% coinsurance*
PPO Plans
Generic — $24
Preferred — $105
Non-Preferred — $300
Home Delivery (61- to 90-day supply) Home Delivery
(61- to 90-day supply)
Generic
Preferred
Non-Preferred
HSA Plan*
Generic — 10% coinsurance*
Preferred — 20% coinsurance*
Non-Preferred — 40% coinsurance*
PPO Plans
Generic — $20
Preferred — $87.50
Non-Preferred — $250
Retail — Non-Network (Up to 31-day supply) Retail — Non-Network
(Up to 31-day supply)
Generic
Preferred
Non-Preferred
HSA Plan*
Generic — 40% coinsurance*
Preferred — 40% coinsurance*
Non-Preferred — 50% coinsurance*
PPO Plans
Generic — $8
Preferred — $35
Non-Preferred — $100

 To fill prescriptions at a non-network pharmacy, members must:

To fill prescriptions at a non-network pharmacy, members must:

  • Pay the full price of the prescription
  • File a completed claim form with ESI within 365 days of the incurred expense. ESI reimburses the cost of the drug at the network discounted amount, less the applicable copayment or coinsurance.
  • Attach a prescription receipt or label from the pharmacy to the claim form. Patient history printouts from the pharmacy are acceptable, but must be signed by the pharmacist. Cash register receipts are acceptable only for diabetic supplies.
Prescription Out-of-Pocket Maximum PPO 600 PPO 1000 Prescription Out-of-Pocket Maximum
Network — Individual
Network — Family
Non-Network
HSA Plan*
Network (Individual) — Combined with Medical
Network (Family) — Combined with Medical
Non-Network — Combined with Medical
PPO 600 Plan
Network (Individual) — $5,100
Network (Family) — $10,200
Non-Network — No Maximum
PPO 1000 Plan
Network (Individual) — $2,100
Network (Family) — $4,200
Non-Network — No Maximum

*All coinsurance amounts apply after deductible has been met.

Diabetes Support Services

Non-Medicare members needing diabetes medications or supplies can receive the following:

  • Lower prescription copayments/coinsurance
  • Preferred glucometer (one per year) and prescribed preferred test strips and lancets1

Diabetic Medications

Diabetic Medications HSA Plan2 PPO Plans
Retail — Network (Up to 31-day supply) Retail — Network
(Up to 31-day supply)
Generic
Preferred
Non-Preferred
HSA Plan2
Generic — 5% coinsurance
Preferred — 10% coinsurance
Non-Preferred — 20% coinsurance
PPO Plans
Generic — $4
Preferred — $17.50
Non-Preferred — $50
Retail — Network (32- to 60-day supply) Retail — Network
(32- to 60-day supply)
Generic
Preferred
Non-Preferred
HSA Plan2
Generic — 5% coinsurance
Preferred — 10% coinsurance
Non-Preferred — 20% coinsurance
PPO Plans
Generic — $8
Preferred — $35
Non-Preferred — $100
Home Delivery (61- to 90-day supply) Home Delivery
(61- to 90-day supply)
Generic
Preferred
Non-Preferred
HSA Plan2
Generic — 5% coinsurance
Preferred — 10% coinsurance
Non-Preferred — 20% coinsurance
PPO Plans
Generic — $10
Preferred — $43.75
Non-Preferred — $125
Retail — Network (61- to 90-day supply) Retail — Network
(61- to 90-day supply)
Generic
Preferred
Non-Preferred
HSA Plan2
Generic — 5% coinsurance
Preferred — 10% coinsurance
Non-Preferred — 20% coinsurance
PPO Plans
Generic — $12
Preferred — $52.50
Non-Preferred — $150
Retail — Non-Network (Up to 31-day supply) Retail — Non-Network
(Up to 31-day supply)
Generic
Preferred
Non-Preferred
HSA Plan2
Generic — 20% coinsurance
Preferred — 20% coinsurance
Non-Preferred — 25% coinsurance
PPO Plans
Generic — Not covered
Preferred — Not covered
Non-Preferred — Not covered
  1. Covered at 100 percent for PPO members or 100 percent after deductible for HSA Plan members, when received through a network pharmacy.
  2. All coinsurance amounts apply after the medical deductible has been met.

Home Delivery & Retail Pharmacy

Members taking maintenance medications must decide whether to receive their prescriptions by home delivery or retail pharmacy. The home delivery benefit covers up to a 90-day supply for 2½ copayments.

Members may fill a maintenance prescription twice at a retail pharmacy while they decide. If the member has not notified ESI of their choice by the third fill of the prescription, the member must pay the full network discounted amount for the prescription.

Specialty Medications

Specialty medications are drugs that treat chronic, complex conditions. They require frequent dosage adjustments, clinical monitoring, specialty handling, and are often unavailable at retail pharmacies.

Accredo is ESI's home delivery specialty pharmacy provider. Specialty drugs must be filled through Accredo. If ESI has identified your medication as being needed immediately, you may get the first fill at a retail pharmacy. After that first fill, you must get that specialty medication through Accredo. Members who continue to go to a retail pharmacy will be charged the full discounted price of the specialty drug.

Split-Order Program
Your provider may advise you to stop taking a specialty medication before a 30-day supply is depleted, typically due to undesirable side effects or lack of effectiveness.

To help avoid cost for medications that will go unused and to reduce waste, the split-fill program allows members to order a 15-day supply of a specialty drug at a time, rather than a full 30-day supply. The copayment is prorated based on the given days' supply dispensed. For example, if the copayment is $35 for a 30-day supply, you pay $17.50 for the first 15-day supply and $17.50 for the second 15-day supply, if a second supply is filled.

For the first three (3) months of taking a new prescription, you will be in regular contact with a Therapeutic Resource Center (TRC) - specialist pharmacists, nurses and doctors - as well as your own health care provider, in order to monitor for any potential complications. By the fourth month, if the medication is to be continued, a full 30-day supply must be ordered.

The split-fill program only applies to specialty drugs that are packaged to allow split-filling and those that are filled through the Accredo specialty mail order pharmacy, beginning with the first fill.

Step Therapy

MCHCP uses step therapy to ensure members get the safest drugs at the best cost possible before moving to a more costly therapy. The step therapy program varies based on the drug prescribed and the provider's recommended treatment plan. Members may be required to try more than one first-step drug.

First-Step Drugs

  • Primarily generic drugs that have been proven safe and effective
  • Lowest copayment or cost applies
  • Drugs must be tried before the plan pays for a second-step drug

Second-Step Drugs

  • Drugs recommended if first-step drugs don’t work
  • Primarily brand-name drugs
  • Higher copayment or cost normally applies
  • Second-step prescriptions processed at a pharmacy for the first time trigger a message to the pharmacist indicating the use of step therapy. Members should speak with their provider about the next plan of action.

One of the following may occur:

  • The provider may decide to prescribe a first-step drug for the treatment plan.
  • If the provider decides treatment requires a second-step drug without trying a first-step drug, preauthorization must be requested from ESI. A higher copayment or coinsurance may apply.

How the Non-Medicare Prescription Plan Works

  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 must decide whether they would like to fill it at a retail pharmacy or through ESI’s Home DeliveryHome Delivery.
    3. Specialty medicationsSpecialty medications must be filled through Accredo, ESI’s home delivery pharmacy provider.
  3. Pay for prescription. Drug costs are based on the drug tier (preferred* brand or generic, or non-preferred) and where the prescription was filled (retail pharmacy or home delivery). PPO Plan members pay a set copayment. HSA Plan members pay the full cost of the prescription until deductible is met. After that, they pay coinsurance. See Benefit ChartBenefit Chart for more information.
    1. Some prescriptions are covered at 100 percent. 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 percent 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.

*Preferred drug as determined by ESI.

  • 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.
  • 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.
  • 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.
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