Health Pool Pharmacy Program

Important Notices:

Prescription Drug Benefit Summary:

  • No Calendar Year Benefit Limit
  • $200 Annual Deductible for Plans I, II & III
  • $500 Annual Deductible for Plan IV
  • $1,450 Annual Deductible for High Deductible Health Plan/
    HSA-Qualified Plan V

 I.  Retail Pharmacy Copays (up to a 30-day supply)

  • Generics………………….$10
  • Formulary Brands………$25 (plus cost difference if generic available)
  • Non-Formulary Brands..$40 or 50% of the cost of the drug, whichever is greater
    (plus cost difference if generic available)

 II.  Medco Mail Order Pharmacy Copays (up to 90-day supply)

  • Generics…………………. $25
  • Formulary Brands……… $60 (plus cost difference if generic available)
  • Non-Formulary Brands…$100 or 50% of the cost of the drug, whichever is greater
    (plus the cost difference if generic is available)

III.  Specialty Medication Medication Copays:  $100  (30-day supply)

  • Specialty Medications are prescription drugs that cost $500 or more per dose, or $6,000 or more per year,* and have one or more of the following characteristics:
  • Complex therapy for complex disease
  • Specialized patient training and coordination of care (services, supplies, or devices) required prior to therapy initiation and/or during therapy
  • Unique patient compliance and safety monitoring requirements
  • Unique requirements for handling, shipping, and storage
  • Potential for significant waste due to the high cost of the drug

*Exceptions to the price threshold may exist based on certain characteristics of the drug or therapy which will still require the drug to be classified as a specialty drug. In addition, a follow-on biologic or generic product will be considered a specialty drug if the innovator drug is a specialty drug.

Specialty Drug List link:  Specialty Medications

  • Certain specialty medications are covered by the Pool only when they are provided through the Pool’s pharmacy benefit, by Express-Scripts–Medco/Accredo.  These medications consist of all hemophilia factor, growth hormone medications, and medications to treat metabolic disorders.

 NOTES:

  • The outpatient prescription drug benefit is not available to a Pool enrollee who is also eligible for Medicare.
  •  $1,500 annual cap on copayments for HSA-Qualified Plan V.

 

Express Scripts administers the Pool’s outpatient prescription drug benefit.  If you have any questions
about your prescriptions, please call Express Scripts customer service at:
1-800-280-1604.

IMPORTANT LINKS:

Manage Your Drug Benefit at www.express-scripts.com
Tip: When registering, enter only
your 9-digit numeric ID# in the
Member Number field

Prescription Drug Benefit Handbook —  Regular Plans

Prescription Drug Benefit Handbook — HSAQ Plan

Pool Drug Formulary

 Pharmacy Chain Network

  Retail Prescription Claim Form

Specialty Medications List

Prior Authorization Drug List


Contact Express Scripts by telephone at
1-800-280-1604