Prescription Drug Program - Human Resources at Ohio State

Prescription Drug Program

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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Prescription Drug Program Details

Effective Jan. 1 – Dec. 31, 2018

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Prescription Drug Plan
PRIME CARE ADVANTAGE
PRIME CARE CHOICE
OUT-OF-AREA PLAN
PRIME CARE CONNECT
Annual Out-of-Pocket Maximum1 $2,500 per person, $5,000 per family $2,000 per person, $4,000 per family
Deductible2 $50 per person, $100 per family No deductible
Preferred Pharmacy Non-Preferred Pharmacy Home Delivery or Retail90 Pharmacy3 Preferred Pharmacy Non-Preferred Pharmacy Home Delivery or Retail90 Pharmacy3
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

Infertility Medication Plan4, 5, 6, 7
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 Prescription Drug Program annual out-of-pocket maximum is based on plan enrollment and is separate from the medical plan annual out-of-pocket
maximum.
2 The deductible applies to brand name medications only.
3 Retail90 is Express Scripts’ program which allows individuals to fill their prescriptions for up to a 90-day supply via select retail pharmacies.
4 The infertility treatment medical benefit includes the cost of prescription medications and requires prior authorization from OSU Health Plan.
5 The Prescription Drug Program annual out-of-pocket maximum does not apply to infertility medications.
6 Infertility treatment has a separate lifetime maximum benefit.
7 The infertility drug coinsurance does not have a maximum coinsurance per prescription for formulary and non-formulary brand name medications.

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. (see List of Medications Requiring Prior Authorization)

For greater details about the Prescription Drug Program, refer to the Medical Plans Specific Plan Details 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:

  • Kroger *
  • Giant Eagle
  • Meijer*
  • Wal-Mart*
  • Discount Drug Mart*
  • Rite Aid
  • Marc’s
  • Kmart
  • Sam’s Club*
  • Costco*

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.

*Retail90 available

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.

Effective Jan. 1 – Dec. 31, 2018

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Preventive Drug List
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)
Vitamin D Men and women 65 years or older
Vaccines See OSU Health Plan Forms & Downloads
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

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, 2018

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Specialty Medication Plan
Feature Retail Delivery OSUWMC Pharmacy and Accredo
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

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. (see List of Medications Requiring Prior Authorization)

For greater details about the Prescription Drug Program, refer to the Medical Plans Specific Plan Details document. If the information in this summary differs from the Specific Plan Details document, the Specific Plan Details document will govern.

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.

Prior authorization is required for some medications. 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. (see List of Medications Requiring Prior Authorization)

Faculty, staff and their dependents who are participating in Prime Care Advantage, Prime Care Choice, Out of-Area or Prime Care Connect and 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 copay for certain eligible generic drugs taken for the 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 percent for eligible participants. If you choose not to actively participate in the Care Coordination Program, you are not 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 Value-Based Prescription Drug Plan Design Benefit Guide)

Effective Jan. 1 – Dec. 31, 2018

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Value Based Drug Plan1, 2, 3
PRIME CARE ADVANTAGE
PRIME CARE CHOICE
OUT-OF-AREA PLAN
PRIME CARE CONNECT
Preferred Pharmacy Home Delivery or Retail90 Pharmacy3 Preferred Home Delivery or Retail90 Pharmacy3
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.

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. (see List of Medications Requiring Prior Authorization)

For greater details about the Prescription Drug Program, refer to the Medical Plans Specific Plan Details document. If the information in this summary differs from the Specific Plan Details document, the Specific Plan Details document will govern.

Effective Jan. 1 – Dec. 31, 2018

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Women’s Health/Contraceptive Coverage
Drug/Device Category Eligibility Criteria
At least one form of women’s contraception in each of the 18 “methods” of contraception outlined in the FDA birth control guide. See OSU Health Plan Forms & Downloads Women only. No age restriction.

Effective Jan. 1 – Dec. 31, 2018

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Tobacco Cessation Coverage
Drug Category Eligibility Criteria
Prescription and Over-the-Counter products with a physician prescription. Men and women age 18 and older.

Prescription Drug Program FAQ

Prescription drug coverage is included in all Ohio State medical plans. See rates for medical coverage.

No. Your medical ID card serves as your prescription card.

See the Prescription Drug Formulary Guide for a list of covered medications.  You might also find your medication on the list of Medications Requiring Prior Authorization.

The Prescription Drug Plan, VBD and Specialty Plans have a combined deductible and annual out-of-pocket maximum. Refer to the Prescription Drug Plan Summary Chart.

 

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.