Prescription Drug Benefits - Human Resources at Ohio State

Prescription Drug Benefits

Prescription Drug Card
Hard copy prescription cards are no longer mailed by Express Scripts. Instead, your prescription card can be accessed via the Express Scripts website and mobile app. More information can be found below.

The health and well-being of faculty and staff is a priority at Ohio State. All of the benefits available to you reflect Ohio State’s commitment to providing high-quality, affordable medical plans and represent a significant component of your total rewards. Access to prescription drugs is a vital part of our medical coverage.

All of the university’s medical plans include prescription drug benefits through Express Scripts, available via home delivery mail-order service and nationwide retail pharmacy locations. You choose which option is most convenient for you and your family.

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Free At-Home COVID-19 Tests

Residential households in the U.S. can order one set of 4 free at-home tests from COVIDtests.gov. Here’s what you need to know about your order:

  • Limit of one order per residential address
  • One order includes 4 individual rapid antigen COVID-19 tests
  • Orders started shipping in late January

Over-the-Counter COVID-19 Tests

The federal government mandates health insurance coverage pertaining to certain at-home, over-the-counter (OTC) COVID-19 diagnostic tests. Effective January 15, 2022, The Ohio State University Faculty and Staff Health Plan covers up to eight (8) OTC tests per month per covered person. The university’s pharmacy benefit administrator, Express Scripts (ESI) is facilitating this coverage.

You may use your benefit to get your tests at a participating retail pharmacy or through Home Delivery.

How do I obtain a free at-home test kit?

Federal Government
Through the United States Postal Service (USPS), households may request a total of four (4) tests to be delivered for free. To learn more and order at-home tests, visit www.covidtests.gov.
Retail Pharmacy
Purchase the test at the pharmacy counter by presenting your prescription drug information or ID card found in the ESI mobile app.
Home Delivery
Purchase the test through the Express Scripts website at express-scripts.com. Click “Home” at the top of the page, then “Order At-home COVID-19 Tests” on the bottom right hand side of the screen. You may fill out the online form to order tests through Home Delivery. Please keep in mind, there are currently limited supplies and tests may take up to four (4) weeks to arrive. ESI is working to improve their supply and turnaround time.

How do I submit a claim for reimbursement for at-home test kit?

If you pay for the test out of pocket, ask the pharmacy for a receipt and keep all test kit packaging. You will need to submit the test kit packaging (UPC) and the receipt showing the date of purchase and price. Download the manual reimbursement claim form.

You may also submit a claim through the Express Scripts website by logging into express-scripts.com, choose “Benefits” at the top of the page, then “Forms” and then “Request a Reimbursement.” Follow the prompts to start a claim.

How many tests are covered?

The Plan covers up to eight (8) tests per month, per covered member.

Which tests are covered?

With the exceptions noted in this communication, the Plan covers OTC COVID-19 tests authorized by the U.S. Food and Drug Administration (FDA). Some examples of the FDA-authorized brands include:

  • COVID-19 AT-HOME TEST
  • INTELISWAB COVID-19 HOME TEST
  • BINAXNOW COVID-19 AG SELF TEST
  • QUICKVUE AT-HOME COVID-19 TEST
  • IHEALTH COVID-19 AG HOME TEST
  • ELLUME COVID-19 HOME TEST
  • ON-GO COVID-19 AG AT HOME TEST
  • FLOWFLEX COVID-19 AG HOME TEST

The Plan covers tests only when they are purchased for the personal use of individuals covered under the Plan. Members cannot use tests covered by the Plan for any other purpose. Members may be asked to acknowledge that any use other than personal use constitutes fraud under the terms of the Plan.

Which tests are not covered?

This coverage requirement does not include tests used for employment purposes or those that use a self-collected sample but require processing by a lab.

How can I get reimbursed for a covered test prior to the network being established?

If you purchase covered tests on or after January 15, 2022, from any retailer, you may submit a manual reimbursement claim through ESI. You will need to submit the test kit packaging (UPC) and the receipt showing the date of purchase and price. Download the manual reimbursement claim form.

You may also submit a claim through the Express Scripts website by logging into express-scripts.com, choose “Benefits” at the top of the page, then “Forms” and then “Request a Reimbursement.”  Follow the prompts to start a claim.

What if I purchased a test prior to the effective date of the mandate, January 15, 2022?

If you purchased a test prior to January 15, 2022, you are not eligible for reimbursement through this program.

Where and when can I buy tests with no out-of-pocket cost?

You may purchase the at home test kits at pharmacies in the ESI Express Advantage Network or through the Express Scripts website. Eligible test kits will process as a pharmacy claim, with $0 out of pocket expense. You must present your prescription drug member identification information found in the ESI mobile app to obtain these covered tests at a network pharmacy.

Can I purchase an at-home test with no out-of-pocket cost through Home Delivery?

Yes, log in or register at expressscripts.com to place a test kit order through Home Delivery. Please keep in mind, there are currently limited supplies and tests may take up to four (4) weeks to arrive. ESI is working to improve their supply and turnaround time.

Prescription Drug Benefits Details

Hard copy prescription cards are no longer mailed by Express Scripts. With the Express Scripts mobile app, you can access your prescription card and manage your prescriptions. If you prefer a paper card, you have the option to print a card from the Express Scripts website.

First you need to register with Express Scripts, using one of these methods:


Text JOIN to 69717 for a link to our registration page

Visit your device’s app store to download the Express Scripts mobile app

Note: First-time visitors must register using their member ID number or Social Security Number. When you download the Express Scripts mobile app, you can use the same username and password as your online account. After registration, you can log into the mobile app.

In addition to accessing your prescription card, here are other ways to use the app:

  • Connect with pharmacists 24/7.
  • Control how you hear from Express Scripts.
  • Order refills, track shipments, compare prices and access plan information.

Effective Jan. 1 – Dec. 31, 2022

Prescription Drug Plan1 PDF Version of Prescription Drug Summary
PRIME CARE ADVANTAGE
PRIME CARE CHOICE
OUT-OF-AREA PLAN
PRIME CARE CONNECT
Annual Out-of-Pocket Maximum2 $2,500 per person, $5,000 per family $2,000 per person, $4,000 per family
Deductible3 $50 per person, $100 per family No deductible
Preferred Pharmacy Non-Preferred Pharmacy Home Delivery or Retail90 Pharmacy4 Preferred Pharmacy Non-Preferred Pharmacy Home Delivery or Retail90 Pharmacy4
Supply Limitations 30-day supply 30-day supply 90-day supply 30-day supply 30-day supply 90-day supply
Generic Drug $10 copay $20 copay $25 copay $8 copay $18 copay $20 copay
Formulary Brand Name Drug 30% coinsurance, up to $100 35% coinsurance, up to $110 30% coinsurance, up to $250 30% coinsurance, up to $40 35% coinsurance, up to $50 30% coinsurance, up to $100
Non-Formulary Brand Name Drug 50% coinsurance, no maximum 55% coinsurance, no maximum 50% coinsurance, no maximum 50% coinsurance, no maximum 55% coinsurance, no maximum 50% coinsurance, no maximum
1 Specific preferred insulin products will be available for a $25 copay per $30-day supply and a $75 copay per 90-day supply through the Express Scripts Patient Assurance Program. The insulin products included in this program are Humulin, Humalog and Lantus.
2 The Prescription Drug Plan annual out-of-pocket maximum is based on plan enrollment and is separate from the medical plan annual out-of-pocket maximum.
3 The deductible applies to brand name medications only.
4 Retail90, also known as Smart90, is Express Scripts’ program which allows individuals to fill their prescriptions for up to a 90-day supply via select retail pharmacies.

NOTE: The Prescription Drug Plan, Value-Based Drug Plan and Specialty Medication Plan designs have a combined deductible and annual out-of-pocket maximum.

Certain prescription drugs require prior authorization. Once approved, the authorization is valid for up to one year. If a prescription drug requiring prior authorization is not approved for coverage under the plan, you will be responsible for paying the full cost of the medication.

For greater details about the Prescription Drug Program, refer to the 2022 Health Plan Specific Plan Details (SPD) document. If the information in this summary differs from the Specific Plan Details document, the Specific Plan Details document will govern.

Express Scripts offers prescription drug benefits through nationwide retail pharmacy locations and a home delivery mail-order service.

Retail – Express Advantage Network and Retail90

You may use your retail benefit for prescription medications required on a short-term basis, such as antibiotics, or for a 30-day supply of medications used on a continuing basis. The Express Advantage Network allows members to take advantage of higher savings at a preferred retail network pharmacy. You may still use retail pharmacies that do not participate in the Express Advantage Network, but your out-of-pocket costs will be higher if you use a non-preferred retail pharmacy. If you utilize an excluded pharmacy (not listed as preferred or non-preferred), you will be responsible for paying the full cost of any medication.

In addition to a 30-day supply, you may also utilize Retail90 (also known as Smart90) which allows you to fill a 90-day supply of medication at certain preferred pharmacies in the Express Advantage Network.

To locate a network pharmacy, use the Locate a Retail Pharmacy tool offered by Express Scripts. When you have a prescription filled at a network pharmacy, present your medical/Rx card to the pharmacist, who will use an automated system to verify your coverage and prescription cost.

Examples of pharmacies in the preferred retail network include, but are not limited to:

  • Costco*
  • Discount Drug Mart*
  • Giant Eagle*
  • Kroger*
  • Marc’s
  • Meijer*
  • OSU Outpatient Pharmacy*
  • Rite Aid*
  • Walmart*

*Retail90 available

To find out the status of your pharmacy or the cost of medications, please contact Express Scripts at (866) 727-5867. Please note that all Walgreens locations are excluded from the Ohio State benefit.

Home Delivery

Express Scripts’ home delivery service provides a convenient and cost-effective way to order a 90-day supply of medicine you take on a continuing basis. Through this program, you can get many of the same maintenance medications that you have filled at a retail pharmacy delivered right to your mailbox. Home Delivery can be used for a new maintenance prescription or refills. Register on the Express Scripts website.

Generic Drugs

Generic drugs must meet the same FDA standards of composition, safety, strength, purity and quality as brand-name drugs. If you receive a generic drug, you will pay a lower amount than for a brand-name drug. The next time you receive a prescription, ask your doctor or pharmacist if a generic alternative is available and appropriate for you.

Formulary

The medications on the Prescription Drug Formulary Guide are chosen based on comparative clinical effectiveness, safety profiles and opportunities to help contain costs.

Non-Formulary

Brand-name medications that are not part of the formulary list are commonly considered non-formulary. Non-formulary brand-name drugs are typically those that have a generic equivalent, are higher cost or are newly released to the market. When a new drug comes onto the market, the Express Scripts Pharmacy and Therapeutics Committee evaluates the drug’s safety and efficacy compared to similar drugs already available.

Exclusions

Certain medications are excluded from the prescription drug plan and not covered. The Faculty and Staff Health Plans Specific Plan Details document has a list of excluded prescription drugs.

The Ohio State University Faculty and Staff Health Plan members who are actively participating in the Care Coordination Program for management of asthma, chronic obstructive pulmonary disease (COPD), diabetes and/or heart disease (coronary artery disease or congestive heart failure) are eligible for the VBD. The VBD copay for certain eligible generic drugs taken for these chronic condition(s) will be waived and the member cost-share for certain eligible formulary brand-name drugs taken for the chronic condition(s) will be reduced by 50%. Only eligible members who choose to actively participate in the Care Coordination Program, are eligible for the VBD. Eligible VBD medications obtained at a non-preferred pharmacy will not receive the VBD discount and will be subject to the applicable benefit copay/coinsurance. (see the 2022 Value-Based Drug Plan Medication Guide)

Effective Jan. 1 – Dec. 31, 2022

Value-Based Drug Benefit1,2,3 PDF Version of Prescription Drug Summary
PRIME CARE ADVANTAGE
PRIME CARE CHOICE
OUT-OF-AREA PLAN
PRIME CARE CONNECT
Preferred Pharmacy Home Delivery or Retail90 Pharmacy4 Preferred Home Delivery or Retail90 Pharmacy4
Supply Limitations 30-day supply 90-day supply 30-day supply 90-day supply
Generic Drug $0 $0 $0 $0
Formulary Brand Name Drug 15% coinsurance, up to $50 15% coinsurance, up to $125 15% coinsurance, up to $20 15% coinsurance, up to $50
Non-Formulary Brand Name Drug 50% coinsurance, no maximum 50% coinsurance, no maximum 50% coinsurance, no maximum 50% coinsurance, no maximum
1 The Value-Based Drug Plan eligibility is based on actively participating in the Care Coordination Program for management of specific chronic conditions (asthma, chronic obstructive pulmonary disease (COPD), diabetes, and heart disease). Visit yp4h.osu.edu to learn more about the Care Coordination Program.
2 Non-Formulary Brand Name Drugs are not eligible for the Value-Based Drug Plan.
3 The Value-Based Drug Plan is not available at Non-Preferred Pharmacies. NOTE: The Prescription Drug Plan, Value-Based Drug Plan and Specialty Medication Plan designs have a combined deductible and annual out-of-pocket maximum.
4 Retail90, also known as Smart90, is Express Scripts’ program which allows individuals to fill their prescriptions for up to a 90-day supply via select retail pharmacies.

Certain prescription drugs require prior authorization. Once approved, the authorization is valid for up to one year. If a prescription drug requiring prior authorization is not approved for coverage under the plan, you will be responsible for paying the full cost of the medication.

For greater details about the Prescription Drug Program, refer to the 2022 Health Plan Specific Plan Details (SPD) document. If the information in this summary differs from the Specific Plan Details document, the Specific Plan Details document will govern.

Specialty medications are usually high-cost pharmaceutical products that are generally, but not exclusively, biotechnological in nature. The Ohio State Wexner Medical Center Outpatient Pharmacy and Accredo specialty pharmacy through Express Scripts are the only pharmacies in the exclusive specialty network. If you do not have your specialty medication filled at one of these two pharmacies, it will not be covered.

Effective Jan. 1 – Dec. 31, 2022

Specialty Medication Plan1 PDF Version of Prescription Drug Summary
Feature Retail Delivery OSUWMC Pharmacy and Accredo2
Supply Limitations 30-day supply
Generic Drug Not Available 20% coinsurance, up to $50
Formulary Brand Name Drug 20% coinsurance, up to $100
Non-Formulary Brand Name Drug 50% coinsurance, no maximum
1 Certain specialty medications are included in the SaveonSP copay assistance program and subject to a different copay structure. While there are copays associated with each product included in the SaveonSP program, the member copay will be $0. If an individual chooses not to enroll in SaveonSP, they will be responsible for the prescription drug copay for qualified medications, and the copay amount will not apply to the Prescription Drug Program out-of-pocket maximum.
2 In certain cases, the outpatient pharmacy at Nationwide Children’s Hospital may also fill prescriptions under the Specialty Medication Plan. Contact OSU Health Plan for details.

For greater details about the Prescription Drug Program, refer to the 2022 Health Plan Specific Plan Details (SPD) document. If the information in this summary differs from the Specific Plan Details document, the Specific Plan Details document will govern.

Express Scripts has partnered with SaveonSP to offer a prescription copay assistance program for members taking certain specialty medications. The SaveonSP program takes advantage of available pharmaceutical manufacturer assistance dollars which helps to reduce the cost of the medication for members and the plan. By changing the plan design to increase the member’s cost share for select specialty medications, the copay assistance available from the manufacturers of those medications can be maximized, which will result in the medication becoming available to you with zero ($0) out-of-pocket cost.

This program is available through each of the existing pharmacies in the exclusive specialty pharmacy network for Ohio State’s plan: Accredo, OSU Outpatient Pharmacy, and Nationwide Children’s Hospital. Members who take a medication on the SaveonSp List are eligible to participate and begin enjoying savings in 2020 once they enroll in the SaveonSP program by calling SaveonSP at 1-800-683-1074.

Enrollment is voluntary, however, if you choose not to participate in the SaveonSP program, you will be responsible for the entire increased copay amount for the SaveonSP specialty medications you fill beginning January 1, 2020. It is also important to note that these copay amounts do not apply toward your annual deductible or out-of-pocket maximum.

The Patient Assurance Program offers savings to members who use insulin products to manage their diabetes. It provides a 30-day supply of certain insulin medications for no more than $25 or a 90-day supply for no more than $75 when obtained at preferred pharmacies.

Effective Jan. 1 – Dec. 31, 2022

Infertility Medication Plan1, 2, 3, 4 PDF Version of Prescription Drug Summary
Feature Retail Delivery Home Delivery
Lifetime Maximum Benefit $15,000
Supply Limitations 30-day supply
Generic Drug 20% coinsurance, up to $50 20% coinsurance, up to $50
Formulary Brand Name Drug 30% coinsurance, no maximum 30% coinsurance, no maximum
Non-Formulary Brand Name Drug 50% coinsurance, no maximum 50% coinsurance, no maximum
1 The infertility treatment medical benefit includes the cost of prescription medications and requires prior authorization from OSU Health Plan.
2 The Prescription Drug Program annual out-of-pocket maximum does not apply to infertility medications.
3 Infertility treatment has a separate lifetime maximum benefit.
4 The infertility drug coinsurance does not have a maximum coinsurance per prescription for formulary and non-formulary brand name medications.

For greater details about the Prescription Drug Benefit, refer to the 2022 Health Plan Specific Plan Details (SPD) document. If the information in this summary differs from the Specific Plan Details document, the Specific Plan Details document will govern.

If using a preferred pharmacy and with a prescription, the medications on the preventive list are covered with no out of pocket cost to the member if eligibility criteria are met.

Preventive Drug List PDF Version of Prescription Drug Summary
Drug Category Eligibility Criteria
Aspirin for cardiovascular disease Men age 45 to 79 years AND
Women age 55 to 79 years
Aspirin for preeclampsia Women of child-bearing years, who are at increased risk of preeclampsia after 12 weeks gestation
Oral fluoride supplementation Children from birth through 5 years old
Iron supplementation in children Children from birth to 12 months of age
Folic acid supplementation All women planning or capable of pregnancy
Breast cancer prevention Subject to Prior Authorization:

  • Tamoxifen (generic)
  • Raloxifene (generic)
  • Soltamox (Tamoxifen liquid) (brand)
  • Anastrozole (generic)
  • Exemestane (generic)
Vaccines See Preventive Health Care Guidelines available online at
osuhealthplan.com under Forms and Downloads
HIV Pre-Exposure Prophylaxis Emtricitabine/Tenofovir Disoproxil Fumarate (generic)
Bowel Preparations Certain bowel preparation agents for screening colonoscopy for men and women ages 50 to 75 years
Statin drugs for the primary prevention of cardiovascular disease Low- to moderate-dose statins for men and women age 40-75 years. These medications include:

  • Atorvastatin
  • Fluvastatin IR and XL
  • Lovastatin
  • Pravastatin
  • Simvastatin
  • Rosuvastatin
Women’s Health/Contraceptive Coverage PDF Version of Prescription Drug Summary
Drug/Device Category Eligibility Criteria
At least one form of women’s contraception in each of the Women only. No age restriction.
18 “methods” of contraception outlined in the FDA birth control guide. See Preventive Health Care Guidelines available online at osuhealthplan.com under Forms and Downloads.
Women only. No age restriction.
Tobacco Cessation Coverage PDF Version of Prescription Drug Summary
Drug Category Eligibility Criteria
Prescription and Over-the-Counter products with a physician prescription. Men and women age 18 and older.

If you are a pet parent, you know nothing can replace the love of our furry family members. However, just like humans, health care costs for pets can be expensive. Especially if you are dealing with expenses for prescriptions treating chronic conditions such as diabetes, anxiety, arthritis, or heart disease, it can be a real burden to your budget.

But help is on the way – Ohio State, through our partnership with Express Scripts, will provide savings opportunities for Ohio State employees when purchasing certain prescriptions for pets. Inside Rx Pets is a program offering for certain human medications that are also prescribed for veterinary use and available through a network of participating pharmacies. On average, it provides a savings of 75% on generic medications and 15% on brand medications for pet owners purchasing these medications for their pets.

Visit the Inside Rx Pets website to learn how to get started.

 

This is intended to be an overview. Refer to the Plan Document for complete information. In the event the information on these pages differs from the Plan Document, the Plan Document will govern.