Prescription Drug Benefits

With the Express Scripts mobile app, you can access your prescription card virtually 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:

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 virtual 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.

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

Retail – Express Scripts Retail 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 Scripts Retail 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 Scripts Retail 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 digital 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*
• CVS*
• Discount Drug Mart*
• Giant Eagle*
• 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 and Kroger 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 Value-Based Prescription Drug Plan (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.

• Value-Based Drug Plan Medication Guide

Specialty medications are frequently high-cost pharmaceutical products that are biotechnological in nature and available only through specialty pharmacies. 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.

• Specialty Medication Benefit

Weight management can often prevent or improve the effects of chronic diseases and enhance overall health. In recent years, strategies that include GLP-1 medications have shown early indications for being highly effective in the treatment of obesity.  Coverage of certain medications used for weight-loss; Wegovy, Zepbound and Saxenda, require participation in the EncircleRx Weight Loss Program with Express Scripts as well as meeting certain coverage requirements.  If the required criteria are not met, GLP-1 medications used for weight loss will not be covered.

There is a 30-day supply limit for GLP-1 medications used for weight loss.

All questions about the EncircleRx Weight Loss Program can be answered by calling Express Scripts directly at 866-727-5867.

Frequently Asked Questions

Is coverage for GLP-1 weight-loss medications changing?
Yes. Announced during the Open Enrollment period in November 2024, changes are being made to the Plan to retain coverage of these GLP-1 weight-loss medications in 2025 for eligible individuals.

How is coverage for GLP-1 weight-loss medications changing?
Effective January 1, 2025, there will be a 30-day supply limit for the GLP-1 medications used for weight-loss.

Beginning March 1, 2025, GLP-1 weight-loss medication coverage will be dependent on members meeting new coverage requirements.

What medications are included?
Wegovy, Zepbound and Saxenda. These are all GLP-1 medications approved by the U.S. Food and Drug Administration (FDA) for weight management.

What do I need to do if I am currently taking a GLP-1 medication for weight-loss?
Express Scripts, Ohio State’s prescription drug vendor, will contact participating individuals directly with information about eligibility, enrollment, and participation.

What are the coverage requirements for GLP-1 weight-loss medications?
For a medication to be covered, you must:

• Join and actively engage in the Omada online lifestyle modification program; and
• Have a body mass index (BMI) of 32 or higher before you started the medication – or a BMI of 27 or higher before you started the medication, along with two weight-related health issues.

If the coverage requirements are not met, can I pay out-of-pocket for the GLP-1 drug?
Yes. If all the requirements are not met, the Plan will not cover any portion of the cost of GLP-1 medications for weight loss. You can pay out-of-pocket and/or use your Flexible Spending Account (FSA) funds.

I take a GLP-1 drug for diabetes. Is there a change to my coverage?
No. If you take a GLP-1 for a diagnosis of diabetes, your coverage is not affected by the changes.

How do I know what my BMI is?
BMI, or body mass index, is a measure of your body composition based on your height and weight. Your provider can tell you what your BMI is, and they will work with Express Scripts to provide that information for review.

What weight-related health issues are included in the requirements for coverage of a GLP-1 weight loss medication?
If your BMI is between 27 to 31 and you have two weight-related issues, you can qualify for coverage in EncircleRx Weight Loss.* The health issues associated with being overweight vary. Please talk to your doctor about issues you may be experiencing and whether they may meet coverage requirements.

*You will also need to enroll and actively participate in the Omada lifestyle modification program.

Who is Omada?
Omada has partnered with Express Scripts, Ohio State’s prescription drug vendor, to provide virtual programs that help provide support for health conditions. The health coaches available to you through their program are experts in weight-loss and obesity disease management, and through the program, you have access to tools and support resources to help manage weight and achieve additional health benefits. Omada can help you build healthy routines around what you like to do and where you need the most support. Working with a virtual care team, you can get assistance with reaching your goals through one-on-one health coaching and specialist support, use of smart devices, at no extra cost to you.

How do I get started with Omada?
A letter with the enrollment instructions was mailed to your home address on December 13, 2024. Once you have received your letter, you may enroll in Omada at omadahealth.com/esi and enter the Access Code provided.

Prior to receiving a prescription for a weight-loss medication, I was already enrolled and participating in enrolled and participating in Omada for Prevention* Do I have to start over or re-enroll?
No, if you are actively participating in an Omada program, there is nothing additional you need to do. However, your active engagement in Omada is now required to maintain coverage of GLP-1s. If you currently do not have a scale, Omada will provide one when you start a weight-loss medication.

*Voluntary participation in Omada for Prevention may have previously been offered to individuals who are overweight (based on BMI), have prediabetes, or are at risk of diabetes.

What does “active engagement” with Omada mean?
Active engagement is defined as four weigh-ins and four app engagements per month. App engagements are not restrictive or specifically defined because everyone’s journey is unique and different. An engagement can be a completed lesson, a conversation with your health coach, meal tracking, adding to a peer group conversation, completing an exercise goal or many of the other activities offered by Omada. A weigh-in simply requires stepping on your scale each week and allowing it to record your weight for the day. If you previously enrolled in Omada for Prevention voluntarily, you may already be used to these activities. Your continued engagement is now a requirement to maintain coverage of GLP-1s for weight loss.

Once I am enrolled in Omada, what happens next?
Your coach will reach out to introduce themselves, and you will receive your scale and any additional equipment necessary based on your initial enrollment responses. For the first 30 days, simply enrolling is enough to meet the engagement requirements while you wait for your equipment.

Is enrollment in Omada enough to meet the new coverage requirements?
No. There are two requirements to maintain coverage of GLP-1 medications for weight loss. You must meet both requirements outlined above:

• Join and actively engage in the Omada® online lifestyle modification program; and
• Have a body mass index (BMI) of 32 or higher – or a BMI of 27 or higher, along with two weight-related health issues.

I was already on weight-loss medication therapy. What does this all mean for me?
If you were already on a weight-loss medication, a letter outlining the new coverage requirements, and the actions required by you and your physician was mailed to your home address on December 13, 2024. If you have not previously done so, you will be required to enroll in Omada. Your Omada access code and enrollment directions are available on the Express Scripts portal. Please talk to your doctor about your GLP-1 prescription. Beginning February 1, 2025 your doctor can submit documentation required for review by ESI before you need to refill your prescription following the March 1, 2025 program effective date.

Can I get a 90-day supply of weight-loss medications?
No. Wegovy, Zepbound and Saxenda for weight-loss are limited to a 30-day supply only.

Who do I contact with questions about the new EncircleRx Weight Loss Program?
If you have any questions about this new program or the coverage requirements, please contact Express Scripts directly at 866-727-5867.

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. 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.

Get savings for the entire family- including your pets! The Inside Rx Pets card provides savings on human medications that pets need, To get savings bring the Inside Rx Pets card, along with a valid animal prescription- written by a veterinarian or another licensed care provider, to a participating pharmacy that fills prescriptions for animals. Currently, the card cannot be used to purchase medications that are prescribed exclusively for animals, such as parasiticides or vaccines. The Inside Rx Pets card is not insurance and cannot be combined with any insurance benefit, copay assistance program, or other third-party financial benefits. Download a savings card and check the current price of your pet’s prescription online at Inside Rx Pets or by calling customer service at 800-722-8979.